Chapter 27

Health Screening Activities

1. Different agencies and groups generate different guidelines for type and frequency of screening. For example, the American Cancer Society has different Pap screening recommendations than does the U.S. Preventive Services Task Force; the American Congress of Obstetricians and Gynecologists may have yet another recommendation. 2. Most evidence-based guidelines make use of cost-benefit analysis to arrive at their recommendations. 3. Various third-party payors have different policies regarding the type and frequency of screening for which they will reimburse.

Pender's Health Promotion Model

1. Health professionals constitute a part of the interpersonal environment, which exerts influence on persons throughout their life span. 2. Self-initiated reconfiguration of person-environment interactive patterns is essential to behavior change. The next five assumptions are characteristics of people, whom the theorist assumes: 3. Seek to create conditions of living through which they can express their unique human health potential. 4. Have the capacity for reflective self-awareness, including assessment of their own competencies. 5. Value growth in directions viewed as positive and attempt to achieve a personally acceptable balance between change and stability. 6. Seek to actively regulate their own behavior. 7. Interact with the environment in all their biopsychosocial complexity, progressively transforming the environment and being transformed over time. Pender's model has been used extensively in several disciplines in research and professional practice focused on health promotion. As a nurse, you should find Pender's focus applicable to your work.

Pender and Murdaugh (2014) summarized the health promotion process as a series of nine steps

1. Review and summarize data from assessment. 2. Reinforce the client's strengths and abilities. 3. Identify health goals and related behavioral change options. 4. Identify behavioral or health outcomes that will indicate that the plan has been successful from the client's perspective. 5. Develop a behavior change plan based on the client's preferences, on the stages of change, and on "state-of-the-science" knowledge about effective interventions. 6. Reiterate benefits of change and identify incentives for change from the client's perspective. 7. Address environmental and interpersonal facilitators and barriers to behavior change. 8. Determine a time frame for implementation. 9. Commit to behavior-change goals, and structure the support needed to accomplish them.

Health Beliefs

A health promotion assessment would not be complete without investigating an individual's health beliefs. Health beliefs are embedded in one's culture and personal experiences. Culture influences beliefs and practices affecting wellness and disease prevention. For example, some people may use certain foods (e.g., garlic to prevent heart disease, orange juice to prevent a cold) or herbs to protect or restore health. Why do you think it is important for you to respect cultural and religious views while working with clients to adopt personal health goals?

Nutritional Assessment

A nutritional assessment is a key component of an overall wellness assessment. Unhealthy eating habits occur across all ages, ethnicities, and socioeconomic classes. Assessment involves an evaluation of typical eating patterns correlated with physical examination findings and BMI. Body composition is important in identifying health risks. The usual methods for determining body fat composition clinically are by measuring height, weight, circumferences, and skinfolds

Lipid Screening Guidelines

Adults aged 20 years or older—Have a fasting lipid panel at least once every 5 years. If total cholesterol is 200 mg/dL or greater—or high-density lipoprotein is less than 40 mg/dL—then frequent monitoring is required. Children aged 9 to 11 years—Universal screening is recommended, regardless of risk factors for cardiovascular disease (National Guideline Clearinghouse [NGC], 2011). Children aged 2 to 8 years—Screening is recommended if a parent, grandparent, aunt/uncle, or sibling has a history of myocardial infarction, angina, stroke, coronary artery bypass graft/stent/angioplasty, or hyperlipidemia (NGC, 2011).

Breast Cancer Screening

All women should be familiar with how their breasts normally look and feel and report any changes to a healthcare provider right away. Although research does not show a clear benefit for physical breast exams done by either a health professional or by patients for breast cancer screening (ACS, 2016; American Academy of Family Physicians, 2016b), women should be encouraged to discuss the risks and benefits of breast self-examination (BSE) and clinical breast exam with their healthcare provider. KEY POINT: Beginning at age 45 years, women at average risk for breast cancer should have the choice to start annual breast cancer screening with mammograms (American Cancer Society, 2016; Nelson, 2015; NGC, 2016).

Cervical Cancer Screening

All women should begin cervical cancer screening at age 21. Women between the ages of 21 and 29 should have a Pap test every 3 years. They should not be tested for human papillomavirus (HPV) unless it is needed after an abnormal Pap test result. Women between the ages of 30 and 65 should have both a Pap test and an HPV test every 5 years. This is the preferred approach, but it is also okay to have a Pap test alone every 3 years. Women older than age 65 who have had regular screenings with normal results should not be screened for cervical cancer. Women who have been diagnosed with cervical pre-cancer should continue to be screened

Health Promotion

An effective way for you to promote health and wellness to your patients is to be a role model and engage in healthy behaviors yourself. Strive to maintain a healthy BMI. Patients are more apt to listen to your counseling about the importance of a normal BMI if you are a good role model. Do not smoke. Limit alcohol consumption. Exercise or engage in other stress-relieving activities such as yoga/meditation. Eat a well-balanced diet. Get enough sleep/rest. Maintain a healthy work/life balance. Practice preventive medicine (e.g., keep current with health appointments and screenings, annual physicals, dental appointments, and eye exams).

Synthesis

Applying aspects of these reflections on health, health promotion means finding ways to help individuals develop a state of physical, spiritual, and mental well-being. Health promotion activities are useful to all individuals, whether well or sick, because they encourage optimal function. How does this compare to the WHO definition of health promotion you read earlier

Colon Cancer Screening

Both men and women should have a fecal occult blood test using a multiple stool take-home test every year beginning at age 50 and a screening colonoscopy based on risk factors. If there is a strong family history of colorectal cancer or polyps, screening should begin at an earlier age and be conducted more frequently (American Cancer Society, 2013a).

Physical Fitness Assessment

Cardiorespiratory fitness is reflected in the ability to perform large-muscle, moderate- to high-intensity exercise for prolonged periods of time (ACSM, 2013). There are many different modes of testing, such as field tests (walking or running), treadmills, stationary bicycles, and step testing. Results depend on age and gender. Muscular fitness refers to both muscle strength and endurance. Muscle strength is a measure of the amount of weight a muscle (or group of muscles) can move at one time. Muscle endurance refers to the ability of a muscle to perform repeated movements. Flexibility is the ability to move a joint through its range of motion. The most common assessment is to evaluate low back and hip (trunk) flexion. For information and guidelines for assessing physical fitness (cardiorespiratory, muscular, and flexibility), see the Focused Assessment box Health Promotion: Physical Fitness Assessment.

Dental Health Screening

Clients should have regular dental checkups to detect early signs of oral health problems such as tooth decay, gingivitis (gum disease), and oral cancers.

Providing Counseling

Counseling is an interpersonal communication process that helps a client to identify problems and make changes. In the context of health promotion, counseling promotes personal growth and helps clients change their lifestyle. Counseling may be formal or informal, one-to-one or a small-group discussion, face-to-face or offered via telephone or online. Each meeting with a client is a potential counseling session. Individual Counseling Face-to-face interaction may be helpful when clients are attempting major lifestyle change. In an individual session, you can customize and map out the steps required to meet the client's goals. Contracting. Counseling may include writing a contract detailing the client's expected behaviors. Print out the contract and have the client sign it to reinforce his commitment. Suggest that the client post the plan in a location where he will see it often so that it serves as a frequent reminder. Reinforcing. During counseling sessions, remember to reinforce health-promoting behaviors that have already been established. For example, the client who uses tobacco may eat a balanced diet; reinforce the healthy habit to boost self-esteem. Stress to the client that you believe the client can succeed in making the desired behavior change.

Health Promotion Programs

Disseminating Information To recognize a problem and understand the options for change, people need information. Information may be disseminated at three levels, as illustrated in the following examples: Individual level—Teaching a client how to modify his personal dietary intake Group level—Classes offered at the local hospital, prenatal education programs, and worksite programs Community level—A billboard that presents the dangers of smoking, health blogs on the Internet, and health fairs Changing Lifestyle and Behavior These are group-level programs that provide information and offer support for activities such as weight loss, smoking cessation, exercise, nutrition, and stress management. Some include a maintenance program to help sustain the change. Protecting the Environment Environmental control programs promote health by focusing on air and water quality, toxic waste, healthy homes and communities, infrastructure and surveillance, and global environmental health. Assessing Wellness and Appraising Health Risk A wellness assessment tends to focus on the healthy behaviors. It supports positive change to improve health. A health risk appraisal identifies risky behaviors that promote disease. These tools are available on the Internet, in magazines, and at fitness centers.

History and Physical Examination

Health History. Ask the client about family history of health disorders and cause of death of family members. Keep in mind that the accuracy of reporting is higher for relatives without, rather than those affected by, a given disease (Qureshi, Wilson, Santaguida, et al., 2009). Gather the history directly from the client. As always, provide privacy and comfort while conducting the history and exam. Physical Examination. The level of detail of the physical examination depends on the health history. At a minimum, the exam should include vital signs, weight, body mass index (BMI) or waist circumference, auscultation and palpation of the chest and abdomen, inspection of the skin, and palpation of peripheral pulses. Laboratory Studies. Recommended lab work depends on the history and exam findings. For most adult clients, a screening lab consists of a complete blood count, comprehensive metabolic panel (also known as a chem 20 panel), lipid panel, thyroid function panel, and urinalysis (American College of Sports Medicine [ACSM], 2013). Disease-Specific Studies. In clients with known cardiac or pulmonary disease, additional disease-specific studies may be performed

Testicular Cancer Screening

In spite of the low prevalence of testicular cancer, men should be aware that a lump in the testicle or a feeling of heaviness or swelling in the scrotum could be a sign of testicular cancer and should report these findings to their healthcare provider immediately (American Cancer Society, 2012).

Lifestyle and Risk Appraisal

Lifestyle refers to the manner in which a person conducts his life: physically, emotionally, spiritually, and mentally. Lifestyle includes all of the activities that promote optimal living, such as taking responsibility for one's health, physical activity, nutrition, interpersonal relations, spiritual growth, and stress management. You can gather this information by interview or by using a variety of questionnaires. A health risk appraisal (HRA) is a questionnaire that evaluates risk for disease based on current demographic data, lifestyle, and health behaviors. There are many HRA tools available; many are online. See the Focused Assessment box Lifestyle and Risk Assessment.

PLANNING INTERVENTIONS/IMPLEMENTATION

Nutrition To guide people in making nutritional choices that promote health and prevent disease, Exercise Regular physical activity each week, sustained for months and years, can produce long-term health benefits including a lower risk for heart disease, stroke, type 2 diabetes, hypertension, high cholesterol, metabolic syndrome, Lifestyle Changes For healthy living, adults and teens must choose a lifestyle without tobacco and recreational drugs and with little alcohol. Getting enough sleep and managing stress are also important. In general, adults need 6 to 9 hours of sleep a night. Children need more sleep (see Chapter 35). Inadequate sleep is linked to weight gain and obesity.

Levels of Prevention

Primary prevention activities are designed to prevent or slow the onset of disease. Examples include eating healthy foods, exercising, wearing sunscreen, obeying seat belt laws, and keeping up with immunizations. Secondary prevention involves screening activities and education for detecting illnesses in the early stages. Examples are breast self-examination, testicular exams, regular physical examinations, blood pressure and diabetes screenings, and tuberculosis skin tests. Tertiary prevention focuses on stopping the disease from progressing and returning the individual to the pre-illness phase. Rehabilitation is the main intervention during this level. Patients and health providers move among these levels of prevention. For example, a patient hospitalized for a total hip replacement would receive the following: Tertiary prevention strategies focus on helping her recover from surgery, preventing complications of surgery, and, later on, helping her regain her strength and learn to walk again. Secondary prevention strategies may have been used previously, for example, to screen for osteoporosis that leads to bone fragility and fractures. Primary prevention strategies help her after she returns home, for example, limiting her salt intake and eating a balanced diet that is low in fat and refined sugar.

Skin Cancer Screening

Screen during any health assessment or a specialized dermatological exam. A general survey of the skin using the ABCD criteria is a useful approach for assessing for skin malignancy: Asymmetry, Border irregularity, Color variability, Diameter greater than 6 mm. Rapidly changing lesions are also associated with an increased risk for cancer. Any suspicious lesions should be biopsied (Agency for Healthcare Research and Quality, 2014; National Cancer Institute, 2016).

Providing Health Education

Self-care programs typically cover nutrition, exercise, stress management, or disease prevention. Caregiver education programs may teach caregivers how to perform nursing tasks or prevent injuries, or they may provide a list of community resources for respite care.

Life Stress Review

Stressful Life Change Events Likewise, Richard Rahe (1974) identified some stress-inducing life change events and researched their possible effects on health. Rahe discovered that a high score on a life-change event scale is associated with a greater likelihood of a negative health change—that is, the more stressful life change events a person has, the more likely he is to experience a disruption in health. To see and use a life-change event scale, Daily Stresses Other researchers have focused on daily stresses and their effects on actual health or on one's perception of health. Daily stresses involve travel to and from work, taking children to activities, daily chores, waiting in lines at shops, raising teenagers, and traffic jams. Researchers have found these stresses may gradually erode one's coping mechanisms, producing an inability to cope with daily events and an increased likelihood of illness. Hardiness Research has also demonstrated that in the face of life events, some people develop hardiness rather than vulnerability (Abdollahi, Talib, Carlbring, et al., 2016; Steptoe, Deaton, & Stone, 2015). Kobasa (1979) identified hardiness as a quality in which an individual experiences high levels of stress yet does not fall ill. There are three general characteristics of the hardy person: Control—belief in the ability to control the experience Commitment—feeling deeply involved in the activity producing stress Challenge—ability to view the change as a challenge to grow If you need additional information on hardiness, review Chapter 11.

Prostate Cancer Screening

The U.S. Preventive Services Task Force (USPSTF) recommends against routine prostate-specific antigen (PSA)-based screening for prostate cancer but understands that some patients may request testing. PSA screening should be done only if it includes shared decision making that enables an informed choice by patients. However, healthcare professionals may consider offering the PSA and digital rectal exam (DRE) yearly to men age 50 years and older at risk for prostate cancer and with at least a 10-year life expectancy. If there are risk factors, testing should begin at age 40 to 45 years (American Cancer Society, 2013a).

World Health Organization

The World Health Organization (WHO) defines health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" (WHO, 1948). At the first conference for health promotion, WHO defined health promotion as the process of equipping people to have control over, and to improve, physical, emotional, and social health (WHO, 1986).

Wheel of Wellness

The level of wellness progresses from the center to the outer part of the wheel. The center represents the least amount of wellness, and the outer part represents optimal wellness. If one area of an individual's life is not functioning at optimal level, life will not be as fulfilling as it could be. As a nurse, you should assess each dimension for strengths and weaknesses.

Role Modeling

The model should be someone with whom the client identifies. Ideally, the role model should be accessible to the client during the early stages of change. Example: During the next year, Mr. Needham will continue to eat a balanced diet. This allows for interacting and for exchanging information. Nurses also serve as role models. Therefore, we should provide an example of healthy behaviors. It is difficult to advocate for healthy behavior if you do not follow the behavior that you recommend to clients. Imagine the trust a client loses when he finds out that the nurse who tells him not to smoke cigarettes has a two-pack per day habit. To what extent do you role model healthy behaviors? Providing Counseling

Jean Watson

This nursing theorist proposed that health consists of three elements: (1) a high level of overall physical, mental, and social functioning; (2) a general adaptive-maintenance level of daily functioning; and (3) the absence of illness (or the presence of efforts that lead to its absence). She also refers to health as being a state of mind, the perception of the individual. A person may have a terminal illness and yet consider himself healthy (

Health Promotion Versus Health Protection

ealth promotion is motivated by the desire to increase well-being. Health protection is motivated by a desire to avoid illness. For instance, the 40-year-old who begins an exercise program to improve strength and endurance is motivated by the benefits of health promotion. If he starts exercising because his father died of a heart attack at age 50, he may be motivated by the need to protect his health.

Transtheoretical Model of Change

he Transtheoretical Model of Change (Prochaska & DiClemente, 1982) may serve to alter unhealthy behaviors. Health promotion and protection involve either changing the individual's response to the illness-producing stimuli or changing the environment so that the person will be less likely to encounter illness-producing stimuli. Either idea involves change. The Prochaska and DiClemente model identified four stages of change: Stages 2 through 5, in which change is occurring and Stages 1 and 6 that preceded and followed the stages of change. Stage 1 In the precontemplation stage there is no intention to change behavior in the foreseeable future, because patients are unaware or underaware of their problems. They do not yet contemplate change. Stage 2 Contemplation—Patients are seriously thinking about overcoming a problem but have not yet made a commitment to take action. Stage 3 Preparation—Individuals are intending to take action in the next month and are reporting some small behavioral changes ("baby steps"). Stage 4 Action—The plan is implemented; this requires considerable commitment of time and energy. Stage 5 Maintenance—Individuals are working to prevent relapse and they grow increasingly more confident that the change can be sustained. Stage 6 The termination stage completes the maintenance. Persons who enter into the termination stage have changed the behavior and are not in danger of relapse.

Betty Neuman

his nurse theorist describes health as an expression of living energy available to an individual. The energy is displayed as a continuum, with high energy (wellness) at one end and low energy (illness) at the opposite end. Individuals have varying levels of energy at various stages of life. When more energy is generated than expended, there is wellness. When more energy is expended than is generated, there is illness, possibly death

Telephone Counseling

may be used as a primary counseling approach or as follow-up. Clients with hectic schedules may find it easier to arrange telephone counseling than to schedule a face-to-face interaction. The disadvantage is that telephone counseling does not allow you to detect nonverbal communication. When using telephone counseling, set goals and map out the strategy for change just as you would in face-to-face counseling. Let the client know how and when you can be reached if questions arise. If you are using the telephone for follow-up counseling, it is best to schedule a time to speak. Having an appointment helps keep the patient accountable to the expected behavior and to reinforce the information.

Myers, Sweeney, and Witmer

n 2000, these theorists defined wellness as "a way of life oriented toward optimal health and well-being in which body, mind, and spirit are integrated by the individual to live more fully within the human and natural community" (p. 252). This definition includes lifestyles and habits as components of health and permits people who have been diagnosed with disease to be considered healthy.

health promotion diagnosis

s a clinical judgment about a individual's, family's, group's, or community's motivation and desire to increase well being and to actualize health potential. Such motivation and desire are expressed by readiness to enhance specific health behaviors. The diagnosis can be used in any health state along the wellness-illness continuum.