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Health Teaching Education Plan

Carley Mayer

Bachelor of Science Nursing, Loyalist College

NURS 1014, Clinical Practicum: Nursing and Wellness

Professor: Ramona Gheorghe

April 8, 2023
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Health Teaching Education Plan

Health education is an activity that informs and tries to motivate patients to improve their

health with education and empowerment using their existing values and beliefs (Whitehead,

2018). According to Whitehead (2018), health teaching in nursing can be implemented across all

lifespans and settings and can assist in improving patient outcomes. The following includes the

history, implementation, and follow-up of a health teaching education plan to improve outcomes

for resident K.

Patient History

Resident K is an 88-year-old Hispanic female residing in a local nursing home. They

were born in 1935 in Nicaragua. They speak Spanish as a first language and learned English in

Canada when they arrived in 1946. Resident K is comfortable communicating in both languages

and practices the Roman Catholic Religion. Resident K was previously a typist, married, became

a stay-at-home parent, and had two children. During this time, resident K also tutored privately

in Spanish. Resident K's partner is deceased, and their children are still living.

Resident K has a history of frequent falls, nightmares, and urinary tract infections. They

are also diagnosed with GERD, Anxiety, Short-Term Memory Loss, Migraines, Parkinson's,

Paranoia, Hernia, and they have a history of experiencing delirium in new situations, such as

when hospitalized. Resident K takes multiple medications daily to improve symptoms of these

conditions. Resident K has no known allergies.

Concerning Activities of Daily Living (ADLs), resident K can bathe themself with little

assistance, set out their clothing and dress, toilet independently, move in and out of bed, and feed

independently. To determine this information, resident K was scored using the Katz Index of

Independence of Daily Living (Wallace & Shelkey, 2007). at a 6, high patient independence.
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Concerning Instrumental Activities of Daily Living (IADLs), (Graf, 2007) resident K requires

assistance with shopping, travel, food preparation, medication, finances, and housekeeping.

Resident K was scored using the Lawton-Brody Instrumental Activities of Daily Living to

determine this information, scoring a 3, which is low functioning due to the levels of assistance

required for many of these tasks.

General Survey

Resident K is conscious during interaction and is oriented to person, and in some

interactions, they are also oriented to time and place. Their skin was intact, and their last fall

occurred in late January. There is some bruising on the right side of the face inferior to the right

eye. Initially, this was purple in color and about 4cm in length. Over the last four weeks, the

bruise has become lighter and more of a yellow color, and about 2cm of faint yellow bruising

remains. Resident K's face and body appear symmetrical, and they are often well-dressed. Their

gait is slower; however, they can ambulate independently, and their gait improves when using

their walker as a mobility aid. They also are often hunched over when walking, appear stiff, and

tremors of the hands can be observed. Resident K appears to be a healthy weight for their size.

Stress Management

Through weekly conversations with resident K, it was identified that resident K carries a

significant and ongoing level of fear and stress surrounding cameras, radios, and items being

moved and evicted from their residence. Resident K reports that there are children in the halls

each week and reports hearing things that are not there. The conversation is often distorted and

difficult to follow. Sometimes redirection can allow for productive conversation. According to

research by Gnanasekaran (2015), sundowning is known to make behaviour worse in the

afternoon due to biological changes though no common diagnosis or criteria has been formally
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defined. Sundowning also affects resident K in the later afternoon and evening, increasing

symptoms. This makes redirection more complicated and often less productive. In addition,

resident K's short-term memory affects their ability to recall weekly interactions. NADNA

International allows nurses to communicate their professional judgments as a nursing diagnosis

(NANDA International, Inc, 2023). Based on the sum of the interactions with resident K and

with reference to NANDA International, Inc. (2021), resident K struggles with impaired memory

related to difficulty recalling events and retaining new information, as evidenced by paranoia and

memory loss. The phone ringing in the hallway, the paging system, interactions with other

residents, and dining hall noises further exacerbate this. These sounds are frequent and expected

in this residence. This also results in delusions-related anxiety, as evidenced by crying, distress,

and insecurity in engagements with resident K (NANDA International, Inc., 2021).

As a result of these interactions and findings, it is beneficial for resident K's mental

health to reduce stress. According to Yaribeygi et al. (2017), prolonged stress can trigger or

aggravate existing conditions. Prolonged stress can suppress the immune system and cause

cognitive disorders around memory and judgment, mood disorders, and impaired learning

(Yaribeygi et al., 2017). Yaribeygi et al. (2017) also state that these effects have been studied for

over fifty years and that the medical community needs to increase their appreciation of stress's

role in patients' lives and be more willing to consider non-pharmacological interventions in order

to improve outcomes. To achieve stress reduction, resident K was consulted to discuss activities

they enjoyed. In addition to the verbal consultation, resident K's intake paperwork was also

consulted. This information contained activities and suggestions of things once enjoyed by

resident K. The intake paperwork was used to correlate and verify the reliability of resident K's

information from the conversation. Resident K advised verbally and through their intake package
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that they enjoy coloring as this reduces stress and aids their tremors. They also enjoy listening to

music which reduces their stress and further masks the noises that can be a trigger. Finally, they

enjoy reminiscence conversation due to short-term memory loss and visitation, which aids in

loneliness, distracts from triggers, and reduces overall stress. This information was gathered and

built into a health teaching education plan implemented with resident K to reduce their stress

levels.

Health Teaching Education Plan

The first consideration of the plan was how to rate the current stress level to rate the

interventions' success. The Visual Analogue Scale (VAS) was used to rate the current stress level

before and after the interaction (Nurse Nation, 2023). Consideration for the more traditional

Perceived Stress Scale (PSS) (Cohen et al., 1983) was considered; however, due to patient

limitations surrounding cognition, it was most effective to implement a visual tool that could be

easily understood. According to Lesage et al. (2012), the VAS is effective, avoids

misunderstandings in communication, and their study found that it measures perceived stress as

intended. Next, the teaching occurred in a one-on-one environment in resident K's room.

Resident K's preferences were further considered in the printed resources that were brought in,

the colors used, the choice of music, and the topic of the reminiscence conversation.

To begin, a brief introduction and check-in as to how the day has been going was offered.

This was followed by a conversation about current feelings surrounding stress levels in which the

VAS was used. Next was a reminder of the activities we had discussed engaging in with a check-

in to see if it was a good time to engage in them. From here, the general conversation continued

regarding visitations, daily and upcoming events, dinner options, television shows, babies, and

anything else of interest to resident K. As this conversation took place, music was started at an
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appropriate level. The volume should be loud enough to mask most background noise but not so

loud as to interrupt the conversation. Then coloring sheets can be selected, which were at the

recommendation of resident K and were images of interest to them. Markers were also set up in

two stations to facilitate coloring. Resident K preferred to color in their bed, which was

accommodated with a lap desk. The facilitator can engage in coloring but should keep their focus

on conversation and frequently break from their page to ensure the activity remains focused on

the resident's best interest. Resident K was encouraged to color with their artistic freedom. The

conversation should continue to flow and become focused on upbringing, travel to Canada, and

life as an early adult. The activity can be completed when resident K is tired or the set time

elapses. Toward the end of the session, the activity should be tidied for resident K.

The VAS scale was also used after the cleanup was complete to measure the success of

the stress reduction. Once completed, resident K was encouraged to engage in these activities

throughout the week. Additional details supporting health teaching education can be found in the

Appendix.

Modifications

In order to successfully implement the plan, modifications included the type of music,

length of activity, and mood. The original plan included instrumental relaxation music so the

volume would remain stable and not require adjustments, and conversation could flow more

easily. Due to the limitations discussed below, this type of music was not possible. There is also

further evidence in the Appendix that the choice of music by a resident can be as beneficial as

more traditional music. In addition, the original time and duration of activity were shifted as

there were early afternoon activities already planned that resident K engaged in that required a

shift of plans to ensure that too much activity was not engaged in at one time. Finally, the mood
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of resident K required some modification as, at times, resident K was occasionally too upset to

begin an activity due to anxiety and paranoia. When the mood was too challenging to change,

resident K did not use the VAS scale, or the activities were refrained from or rescheduled to

avoid a further behavioral trigger.

In the future, repeating the activities more frequently may be helpful, with additional

locations, music, residents, and reminders in place. According to the research by de Witte et al.

(2020) more engagement was shown to be positively corolated with stress and anxiety reduction.

This means multiple weekly meetings would likely increase the resident's ability to engage and

reduce stress, also improving mental health. Also, in the future, it might be helpful to consider

having the activity as a small, selected group to benefit multiple residents. This could allow

residents with similar stressors to engage and build relationships through conversational

reminiscence and sharing while reducing overall stressors. Next, different types of music, such as

classical, nature sounds, or smooth jazz, could be experimented with to tailor the music to the

resident or group to best cover background noises to avoid triggers and reduce stress. In addition,

reminders to turn on music and engage in activity or with staff or other residents, when

appropriate, and feeling anxious would likely be beneficial. Finally, a baseline of the number of

times that outside noises caused upset could be established to compare this with the findings

during an activity session to further show the reduction of stress levels.

Limitations

Limitations included weekly interactions at set times, which were inhibitory for resident

K. Due to resident K's short-term memory and cognition, they likely would have further

benefited from more encouragement during the week to engage in these activities as they often

forgot. This may have allowed them to succeed further as they would have had more engagement
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regularly. Next, resident K is likely to benefit from interaction at an earlier time of day due to

sundowning, which impacted coherence during the reminiscence conversations. Also, as outside

media could not be brought into the residence, we were limited to using music provided by

resident K's personal device, which did not allow for experimentation of alternative music that

may have had further benefit. Additionally, the inability to document information required

information to be taken by memory which may have resulted in gaps or missing information.

Client Feedback

The healthy education teaching plan for this resident was effective at reducing stress to

improve mental health. Due to the frequency limitations, the plan was not as effective as it might

have been with additional follow-ups and reminders in place. Resident K noted a stress reduction

using the VAS scale from 4 to 3. It is also noted that resident K was less distracted by outside

noises and experienced less paranoia when coloring with music on and engaging in reminiscence

than with just reminiscence itself though this was not formally measured. Resident K also

seemed more relaxed and focused on the activity, and their tremors were reduced slightly.

Unfortunately, much of the conversation was less productive as it was too difficult to follow and

illogical from midpoint to session end; however, resident K's tone remained steady, and they

seemed happy throughout the session.

In conversation immediately following the activity with resident K, resident K said they

enjoyed the activity, music, and conversation. They were eager to know when we would be able

to participate again. They also said they felt more relaxed and were ready for bed. Resident K did

agree to engage in this activity throughout the week and would provide an update. However,

resident K did not remember, likely due to their memory, so additional feedback about

completing the activities independently was unavailable.

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This form of health education allowed resident K to set a goal, work towards this, and

check in to receive feedback. These health promotion activities have informed and motivated

resident K, reducing stress and improving their mental health.

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References

Bradt, J., Potvin, N., Kesslick, A., Shim, M., Radl, D., Schriver, E., Gracely, E. J., &

Komarnicky-Kocher, L. T. (2015). The impact of music therapy versus music medicine

on psychological outcomes and pain in cancer patients: a mixed methods study.

Supportive Care in Cancer : Official Journal of the Multinational Association of

Supportive Care in Cancer, 23(5), 1261–1271. https://doi.org/10.1007/s00520-014-2478-

Cohen, S., Kamarack, T., & Mermelstein, R. (1983). PERCEIVED STRESS SCALE.

https://www.mindgarden.com/documents/PerceivedStressScale.pdf

de Witte, M., Pinho, A. da S., Stams, G.-J., Moonen, X., Bos, A. E. R., & van Hooren, S. (2020).

Music therapy for stress reduction: A systematic review and meta-analysis. Health

Psychology Review, 16(1), 1–26. https://doi.org/10.1080/17437199.2020.1846580

Ferrario, A., Demiray, B., Yordanova, K., Luo, M., & Martin, M. (2020). Social reminiscence in

older adults' everyday conversations: Automated detection using natural language

processing and machine learning. Journal of Medical Internet Research, 22(9).

https://doi.org/10.2196/19133

Gallagher, P., & Carey, K. (2012). Connecting with the well-elderly through reminiscence:

Analysis of lived experience. Educational Gerontology, 38(8), 576–582.

https://doi.org/10.1080/03601277.2011.595312

Good, M., Picot, B. L., Salem, S. G., Chin, C.-C., Picot, S. F., & Lane, D. (2000). Cultural

differences in music chosen for pain relief. Journal of Holistic Nursing, 18(3), 245–260.

https://doi.org/10.1177/089801010001800306
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Graf, C. (2007). The Lawton instrumental activities of daily living (IADL) scale.

https://www.alz.org/careplanning/downloads/lawton-iadl.pdf

Lepere, A. L. (2017). Can coloring reduce stress and increase working memory in the elderly?

[Thesis]. https://digitalcommons.unf.edu/cgi/viewcontent.cgi?article=1796&context=etd

Lesage, F.-X. ., Berjot, S., & Deschamps, F. (2012). Clinical stress assessment using a visual

analogue scale. Occupational Medicine, 62(8), 600–605.

https://doi.org/10.1093/occmed/kqs140

Mayer, C. (2023). Capacity Case Study [Unpublished paper]. Bachelor of Science Nursing,

Loyalist College.

Mind. (2020). Paranoia. Mind. https://www.mind.org.uk/media-a/5947/paranoia-2020.pdf

NANDA International, Inc. (2021). Nursing Diagnoses: Definitions & classification 2021-2023

(S. Kamitsuru, T. H. Herdman, & C. T. Lopes, Eds.; Twelfth). Thieme Medical

Publishers, Inc.

NANDA International, Inc. (2023). Our story. NANDA International. https://nanda.org/who-we-

are/our-story/

Nurse Nation. (2023). 30 horizontal badge reference cards set. In Nurse Nation.

Tortora, G. J., & Derrickson, B. (2020). Principles of anatomy and physiology (16th ed.). Wiley.

Turturro, N., & Drake, J. E. (2020). Does coloring reduce anxiety? Comparing the psychological

and psychophysiological benefits of coloring versus drawing. Empirical Studies of the

Arts, 40(1), 3–120. https://doi.org/10.1177/0276237420923290

Wallace, M., & Shelkey, M. (2007). Katz index of independence in activities of daily living.

https://www.alz.org/careplanning/downloads/katz-adl.pdf
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Whitehead, D. (2018). Exploring health promotion and health education in nursing. Nursing

Standard, 33(8), 38–44. https://doi.org/10.7748/ns.2018.e11220

Yaribeygi, H., Panahi, Y., Sahraei, H., Johnston, T. P., & Sahebkar, A. (2017). The impact of

stress on body function: A review. EXCLI Journal, 16(1), 1057–1072.

https://doi.org/10.17179/excli2017-480

Appendix

Health Teaching Education Plan - Mental Health – Stress Management

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Coloring

The intervention of coloring was selected to improve mental health, specifically to reduce

stress. Other possible benefits included distraction from triggers, reduced tremors, and enhanced

focus.

Coloring and drawing activities have been shown to reduce anxiety and sadness (Turturro

& Drake, 2020). Research conducted by Turturro and Drake (2020) also indicated the benefit of

structuring their activity, though all types of free drawing, structure, and mandalas had positive

results. Similar findings of reduced anxiety were also discovered in studies conducted by Lepere

(2017). According to their research, Lepere (2017) found that coloring provides a pleasurable

and calming activity that reduces stress. They also state that this type of art therapy should be

individualized, with individuals choosing what art they enjoy most for the time they want to

participate (Lepere 2017).

Mind (2020) states that ways to assist paranoia include mindfulness, stress management,

relaxation techniques, and trying a creative activity such as doodling or drawing.

These findings have led to the creation of a resident-specific art health teaching education

plan. Through resident-driven art therapy, resident K can engage in a pleasurable activity. This

activity is self-directed as resident K was invited to engage with any colors and style they

deemed appropriate when they deemed it most helpful. However, there was participation in a

semi-structured activity together when possible. In addition to the act of coloring, the images to

be colored of baby animals were also requested by resident K. These images were provided as

requested to enhance interest, engagement, and likelihood of future engagement. Choosing this

activity, the images, and the colors used gave resident K more autonomy. Resident K was also
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encouraged to continue participating in the activity independently or with others where possible.

The images were left with resident K so they could continue to work on them each week.

Music

Music intervention was selected to improve mental health, specifically to reduce stress.

An additional possible benefit included distraction from triggers (de Witte et al., 2020) and

enhanced focus (Bradt et al., 2015).

While traditionally, music therapy is tailored to the individual or group and is led by a

trained therapist, music medicine also has benefits. According to Witte et al. (2020), music

medicine is defined as "musical interventions offered by healthcare professionals" (p.1). A

comparison study of music therapy and music medicine found that music therapy and music

medicine reduced anxiety and stress (Bradt et al., 2015).

While traditionally, music would be selected with a calmer tempo to listen to, due to

limitations, a patient-selected playlist was chosen. Research by Good et al. (2000) notes that

nurses can consider music with increased volume and tempo and not overlook any music genre if

the patient prefers them. While this study does relate specifically to pain management, the study

also notes that stress reduction is an additional benefit and that sharing music can also build

rapport between a nurse and patient (Good et al., 2000).

With this knowledge in mind, a resident-led music teaching plan was implemented.

Though this was used in conjunction with coloring, if resident K had not wanted to engage in

coloring, music could be offered independently. This music medicine allowed resident K to share

their pleasurable activity and reduce stress. Another benefit to this activity was that background

noises typically triggering resident K were masked, reducing stress. In addition, this also allows
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for autonomy as resident K already has the supplies for their preferred music; they were

encouraged to continue engaging in this activity at will.

Reminiscence

Reminiscence was selected to improve mental health, used in conjunction with coloring

or music, and also to assist in retaining and connecting synaptic connections in the brain.

Reminiscence involves discussions or thoughts of things that occurred in the past

(Ferrario et al., 2020). Recalling or sharing these interventions is used across many disciplines,

including nursing (Ferrario et al., 2020). According to Gallagher and Carey (2012), reminiscing

is a therapeutic nursing intervention for older adults where the adults are asked to share a story

about their childhood or school days. It also noted that reminiscence therapy is included as a

nursing intervention in the Nursing Intervention Classifications (Gallagher and Carey 2012). In

Gallagher and Carey (2012) 's studies, their elderly participants found the activity pleasurable

and increased socialization, self-esteem, and reduced depression in the elderly. While beginning

nursing students cannot provide therapy, they can encourage elders to recall past events,

supporting healthy aging and communication between nurse and patient (Gallagher and Carey

2012).

According to Tortora and Derrickson (2020), by the time a person is about 80, their brain

mass decreases, resulting in a decline of synaptic contacts. This results in a diminishment in

information processing and increased reaction times (Tortora and Derrickson 2020).

These findings have led to semi-structured conversations with remanence at the core.

These activities allowed resident K to discuss their travel to Canada, upbringing, education, and

early marriage. Resident K was invited to share as much or as little information as they found

comfortable. This activity benefited Resident K as they could engage in semi-structured

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reminiscence conversation, which allowed for synaptic connections that may not have been

otherwise triggered. This assists in improving brain function and improves communication. In

addition, Resident K reported less stress after the interaction was complete. Resident K was

invited to continue to engage in conversations and reminisce with other residents and staff at

will.