Health Assessment: Exam 1

Emerging Minority Group Trends

Largest ethnic group/fast-growing minority group: Hispanics Largest racial group: African Americans -Differences noted in age, poverty level, and household composition -All ethnic and racial minority groups exceed the national poverty level -Low educational attainment and lower income are correlated with likelihood of disability -Family size and multigenerational families are more evident in minority groups

The nurse is caring for a patient in the ED who has been a patient many times before in the ED. In fact, this is the patient's second overdose in 1 month. The nurse says, "Here we go again. I don't know why we bother with this guy because he will be back out there as soon as he is discharged" The nuse

Must find a way to come to terms with the way he or she feels

*Cultural Assessment*

The main purpose of assessing culture in a health care setting: >To learn about the client's beliefs and usual behaviors associated with health and illness, including beliefs about disease causes, expected treatment >To compare and contrast client's belief and practice to standard Western health care >To compare the clients beliefs and practices with those of other persons from a similar cultural background (to avoid stereotyping) >To assess the clients health relative to diseases prevalent in the specific cultural group

The nurse has a "hunch" that the patient's elevated blood pressure is due to pain level; however, the patient received blood pressure and pain medication 45 minutes ago. What should the nurse consider in regards to this hunch?

The nurse should consider consulting with the pain management team to evaluate the effectiveness of the pain medication regimen Rationale: The nurse should trust the hunch; however, having another member of the team substantiate the hunch would be a collaborative approach and would provide additional reinforcement for the hunch

What must the nurse assess first when providing culturally competent health care to an Asian American patient?

The nurse's heritage-based cultural values, beliefs, attitudes, and practices -The nurse first needs to be able to determine what biases or differences exist prior to rendering care to any other culture

Intimate partner

any partner (gf, bf, spouse, dating partner, sexual partner) with whole the person has a close relationship that may include emotional connectedness and physical/sexual contact

*Intimate partner violence, child abuse, and elder abuse*

are important health problems that you must recognize the signs of and assess for in every patient

Using this priority principle framework, how would the nurse categorize the patients who arrived at the ED for treatment?

1. A 48 yr old male presenting with chest pain 2. A 68 yr old male who had a ground-level fall 3. A 19 yr old female who has frequent headaches with stable vital signs 48 yr w chest pain = level 1 (cardiac event) 68 yr w fall = level 2 that may escalate to level 1 if there is circulation/vascular problems 19 yr headaches = level 2

Assessment

Assessment: the collection of data about the individual's health state Subjective data: what the person says about himself or herself during history taking Objective data: what you as the health professional observe by inspecting, percussing, palpating, and auscultating during the physical examination Both subjective and objective data form the *database* From the database you make a clinical judgment or diagnosis about the individual's health state, response to actual or potential health problems, and life processes. Thus the purpose of assessment is to make a judgment or diagnosis. Patient's record and lab studies within the EHR Info from the EHR allows the nurse to make a clinical judgment or diagnosis about the patient's health state Key is organization of assessment based on complete factually based data Cluster or group together the assessment data that appear to be causal or associated Ex: With a person in acute pain, associated data are rapid heart rate, increased BP, and anxiety Validate the data you collect to make sure they're accurate. As you validate your info, look for gaps in data collection. Be sure to find missing pieces bc this is an important critical skill!!! Asks for help with validating BP or heart or lung sounds with another nurse if you need it!!

Developmental Competence

Awareness of beliefs across the life cycle can impact perceptions of health care delivery and treatments -Parental perceptions of illness: illness of the child may be partially influenced by religious beliefs Ex: some parents may believe that a transgression against a religious law is responsible for a congenital anomaly in their offspring Ex: other parents may delay seeking medical care because they believe prayer should be tried first -Cultural taboos: implicit prohibition on something Ex: administration of blood, medications containing caffeine, pork, or other prohibited substances Values held by dominant culture influence perception of older adults -Independence, self-reliance, productivity (Dominant values in US) -Care-dependent vs. caregivers (Family taking care of older adults) -Culture shock (state of sudden strangeness, unfamiliarity, and incompatibility with the newcomer's perceptions and expectations)

Chapter 7

Domestic and Family Violence Assessment

Screening Women for Alcohol Problems: *TWEAK* Know what it stands for!

The TWEAK questions are a combination of items of two other questionnaires that help identify at-risk drinking in women, especially pregnant women Instead of the guilt question from the CAGE, the TWEAK includes a question that measures tolerance Tolerance (2pts) -How many drinks can you hold? Or how many drinks does it take to make you feel high? -Taking 3 or more drinks to feel high = Tolerance Worry (2pts) -Have close friends or relatives worried or complained about your drinking in the past year? Eye Opener (1pt) -Do you sometimes take a drink in the morning when you first get up? -Shows dependency Amnesia: (1pt) -Has a friend or family member ever told you about things you said or did that you could not remember? Kut down: (1pt) -Do you sometimes feel the need to cut down on your drinking? -Shows readiness to stop drinking -Scoring 2 or more points = drinking problem

What is a Standard Drink?

about 14 grams of pure alcohol (about 0.6 fl oz or 1.2 tbsp) 12 oz Beer (5% alcohol) 1 standard drink 8-9 oz Malt liquid (7% alcohol) 12 oz=1.5 standard drink; 16 oz=2 standard drinks 5 oz Table Wine (12% alcohol) 25 oz/750mL=5 drinks 3-4 oz Fortified Wine (17% alcohol) 1.5 oz Spirits (40% alcohol) 3 oz Martini (2 standard drinks, 40% alcohol)

Dependence

physiologic dependence on substance

Cue

piece of information, a sign or symptom, or a piece of laboratory data or imaging data

Hypothesis

tentative explanation for a cue or a set of cues that can be used as a basis for further investigation

Objective Data Collection

Be aware of normal range of findings based on developmental age Visual examination of the entire body is required -abuse may be hidden under clothing -atypical bruising pattern or bruise in the shape of an object -significant injury observed in non-mobile individual -Circumflexble injury: Burned waist down and circular they were put in hot water -Spiral fracture: twist their arm Use appropriate terminology r/t bruising -maintain consistency for accurate interpretation Include baseline lab testing -CBC with platelet count, basic blood chemistries, serum LFTs, coagulation panel, and UA Bruise can be used interchangeably with contusion. (Document the size, color, and pattern of any bruises, but do not try to determine timing of injury based solely on the color of the bruise) -New bruise: RED -Develops blue-purple appearance 12-36 hrs after blunt-force trauma -Greenish-brown to brownish-yellow when fading • Laceration is related to avulsion. • Ecchymosis is related to (senile) purpura. • Petechia is related to purpura. • Rug burn is more accurately described as a friction abrasion. • Incision can be used interchangeably with cut. • Cut can be used interchangeably with sharp injury. • Stab wounds are penetrating, deep, sharp injuries. • Hematoma is a collection of blood that is often but not always caused by blunt-force trauma. Multiple factors can contribute to older adults bruising more readily or more severely than younger people. -Medications (e.g., aspirin, anticoagulants, nonsteroidal anti-inflammatory drugs) and abnormal blood values can cause a person to bruise more easily. -Nutritional supplements (e.g., garlic, ginkgo) also contribute to hematologic complications, especially if the person is already taking a blood-thinning or platelet-altering medication. -Any health evaluation for known or suspected elder abuse and neglect should include these baseline laboratory tests: a complete blood count (CBC) with platelet level, basic blood chemistries (including blood urea nitrogen [BUN], creatinine, protein, and albumin), serum liver function tests, a coagulation panel, and a urinalysis.

Examiner Asks Rationale

1. Ask about alcohol use: "Do you sometimes drink beer, wine, or other alcoholic beverages?" If yes: Ask the screening question about heavy drinking days: "How many times in the past year have you had 5 or more drink a day (for men) or 4 or more drinks (for women)? NOTE: One or more heavy drinking days means that this person is an "at-risk" drinker To complete a picture of the person's drinking pattern, ask: "On average, how many days a week do you have an alcoholic drink?" and "On a typical drinking day, how many drinks do you have?" Recommend that the person stay at *low-to-moderate* drinking patterns Recommend even lower levels of abstinence for patients who take medications that interact with alcohol, have a health condition exacerbated by alcohol, or are pregnant NOTE! For men, greater than or equal to 15 drinks/week = *heavy or at-risk* drinking For women, greater than or equal to 8 drinks/week = *heavy or at-risk* drinking 2. Use brief screening instruments to help identify problem drinking and people who need a more thorough assessment. -Ask the patient to respond to the AUDIT questionnaire -A quantitative form has the advantage of letting you document a # for a response so it is not open to individual interpretation -AUDIT helps detect both less severe alcohol problems (hazardous and harmful drinking) and alcohol abuse and dependence disorder NOTE! HAZARDOUS DRINKING: pattern is high-risk for future damage to physical or mental health. Harmful drinking-Alcohol use already results in problems. >It is helpful with ED and trauma patients because it is sensitive to current as opposed to past alcohol problems >It is useful in primary care settings with adolescents and older adults >*It is relatively free of gender and cultural bias* 3. Assess for alcohol use disorders using the standard clinical diagnostic criteria. Determine whether there is a maladaptive pattern of alcohol use causing clinically significant impairment or distress. Ask, "In the past 12 months has your drinking repeatedly caused or contributed to: >*Risk* for bodily harm (drinking and driving, operating machinery, swimming)? >*Relationship* trouble (family or friends)? >*Role failure* (interference with home, work, or school obligations)? >*Run-ins* with the law (arrests or legal problems)? -If yes to one or more, it means that the person has been abusing alcohol. Warrants advice and brief intervention for assistance. -Ask, "In the past 12 months have you: >*Not been able to stick to drinking limits* (repeatedly gone over them)? >*Not been able to cut down or stop* (repeated failed attempts) >*Shown tolerance* (needed to drink a lot more to get the effect) >*Shown signs of withdrawal* (tremors, sweating, nausea, or insomnia when trying to quit)? >*Kept drinking despite problems* (recurrent physical or psychological problems) >*Spent a lot of time drinking* (or anticipates or recovering from drinking) >*Spent less time on other matters* (activities that had been important or pleasurable) -If yes to 2 or more, the person may have alcohol use disorder. Warrants counseling and brief intervention for treatment or mutual help meetings (AA, NA) -If no, patient is still at risk for developing alcohol-related problems. Warrants advice and brief intervention for assistance and close follow-up. -Ask about illicit substances: "Do you sometimes take illicit or street drugs such as marijuana, cocaine, hallucinogens, narcotics? If yes, "When was the last time you used drugs? "How much did you take that time?" 4. Advise and Assist (brief intervention) "You're drinking more than is medically safe" Relate to the person's concerns and medical findings, if present. "I strongly recommend that you cut down (or quit), and I'm willing to help" Or if you determine the person to have an alcohol use disorder, state your conclusion and recommendation clearly: "I believe you have an alcohol use disorder. I strongly recommend that you quit drinking, and I'm willing to help". Relate to the person's concerns and medical findings if present.

The nurse is assessing a patient who admits to being physically abused by her spouse. The patient says, "I wish I would have agreed with my husband, because the I wouldn't have been hit" What is the nurse's best response?

"It is not your fault that your husband lost control. Changing your actions will not prevent him from abusing you again"

Child Abuse and Neglect

*Neglect*: the failure to provide for a child's basic needs (physical, medical, and supervision) -Prenatal drug exposure, child abandonment, and the manufacturing of methamphetamines in the presence of a child are considered neglect in some states -Failure to educate the child is included as neglect in approx. 25 states *Physical abuse*: non-accidental physical injury caused by punching, beating, kicking, biting, burning, shaking, or otherwise harming a child. Even if the parent or caregiver did not intend to harm the child, such acts are considered abuse when done purposefully. -Human trafficking, including labor trafficking and involuntary servitude, is considered physical abuse in approx. 7 states *Sexual abuse*: includes fondling a child's genitals, incest, penetration, rape, sodomy, indecent exposure, and commercial exploitation through prostituition or the production of pornographic materials. Sexual abuse includes human trafficking (sexual trafficking) in 21 states. *Emotional abuse*: any pattern of behavior that harms a child's emotional development or sense of self-worth. It includes frequent belittling, rejection, threats, and withholding of love and support. As a healthcare provider, it is important you know the state definition and state laws related to child abuse and neglect since you are a mandatory reporter As a mandatory reporter, you are REQUIRED to report any known or suspected child abuse or neglect

Developmental Competence: Aging Adult

-An increasing # of older adults are drinking (50.9% alcohol-use; 17% heavy drinkers) -Characteristics that increase risks associated with alcohol use: >Liver metabolism, body water, and kidney function are decreased, which increases bioavailability of alcohol in the blood for longer periods of time >Lose muscle mass; less tissue to which the alcohol can be distributed means as increased alcohol concentration in the blood >Polypharmacy may interact with alcohol >Increases risk of cognitive decline >Increases risk for falls, depression, GI problems, toxic reactions, and fatal overdoses -May avoid detection of of their alcohol problems and alcohol-related consequences; they may no longer drive so they avoid DUI or they may avoid job problems because they no longer work -Both men and women have a higher prevalence of current drinking -Older women have significantly more binge drinking

Withdrawal Symptoms

-Craving for alcohol -Irritability -Anorexia -Abdominal pain -Fatigue Signs are: -Chills -Muscle cramps -Palpitations -Tachycardia -Hypertension -Fever -Disorientation -Slurred Speech -STAGGERED GAIT -Poor dexterity

Developmental Competence: Pregnant Woman

-Dangers to mother as well as to fetus -Alcohol slips easily through the placenta; a defined dose that is easily metabolized by an adult woman is toxic to a fetus who weighs only grams or a few pounds -Alcohol toxicity results in physical, learning, behavioral problems in a fetus that are defined in the Fetal Alcohol Spectrum Disorder -NO AMOUNT OF ALCOHOL OR ILLICIT DRUGS IS DETERMINED SAFE FOR PREGNANT WOMEN -Public awareness and health teaching have reduced the # of US pregnant women who drink alcohol -All women who are contemplating pregnancy or who are pregnant should be screened for alcohol use, and abstinence should be recommended

Barriers to Treatment of Intimate Partner Violence

-IPV is significantly higher among ethnic and racial minorities than among non-Hispanic white women and men. Also, multiracial like American-Indian/Alaskan native, and non-Hispanic black women and men. -*Societal stressors*: contribute to daily struggles and conflicts in relationships Ex: Poverty is a risk factor for IPV -All ethnic and racial minorities have poverty rates exceeding the national average for non-Hispanic whites -Help-seeking is often deferred because of fears of racism or discrimination -Because of past experiences of prejudice and discrimination by health care providers and lack of knowledge of the culture, many immigrants and members of racial and ethnic minorities are reluctant to seek help in the healthcare setting *Legal status*: creates barrier to care for many immigrant families -If a women does not have legal status or citizenship within the US, she may fear that she will be deported and lose her children -Many immigrant women are unaware of their legal rights in situations of IPV -The Violence Against Women Act (VAWA) offers assistance to IPV survivors and includes protections for immigrant survivors -VAWA includes stipulations for coordinating services between law enforcement, victim services, and attorneys; training personnel to provide services; and funding programs to help victims *Lack of access to culturally appropriate care*: continual problem -Immigrants and ethnic minorities less likely to use social service resources -Traditional gender roles reinforce dependency and may increase the risk for IPV against women -In some cultures, the traditional belief is that a man has the right to physically discipline his wife. In these cases, the women may not report violence because they expect it as a social norm. In other cases, women may feel stigmatized if they speak out against violence -To address barriers to care, recommendations include bilingual bicultural providers, access to translator, education about legal rights, incorporation and acknowledgment of the importance of religion and training religious leaders, and involvement of family and outreach to the community to understand the meaning and experiences of IPV for each person and to account for his or her cultural belief and values

Health Effects on Violence

-Immediate and long-term effects -Most obvious immediate health care problem is injury -Traumatic brain injury, headaches, and pain are directly associated with the injury received -Victims of abuse has significantly more chronic health problems, including more cardiovascular, endocrine, immune, GI problems -Women who are ivtims of abus have more gynecologic problems and negative consequences during pregnancy (e.g., preterm birth, low-birth-weight babies, perinatal deaths) -Abuse during pregnancy is also a significant health problem, with serious consequences for both the pregnant mother (e.g., depression, substance abuse) and infant (e.g., low birth weight, increased risk of child abuse) -Abuse victims have significantly more depression, suicidality, PTSD, problems with substance abuse -Rape victims are 3x more likely to use marijuana and 6x more likely to use cocaine than non-victims -Forced sex contributes to a host of reproductive health problems including chronic pelvic pain, unintended pregnancy, STDs, and UTIs -Child maltreatment can have deleterious effects on a child's quality of life and may lead to overall poor health, which can last into adulthood -Children who are abused have an increased incidence of improper brain development, cerebral palsy due to head trauma, delayed language development, and mental health issues (depression, anxiety), and they are at a higher risk for chronic diseases such as obesity, cardiovascular disease, cancer, and high BP -Childhood abuse and neglect increase the likelihood of juvenile arrest, teen pregnancy, and adult criminal behavior

*Importance of Cultural Awareness*

-Increased understanding of cultural diversity by being self-aware and knowledgable about one's own culture -Awareness is an interactive and ongoing process for members of the health care profession -Part of forming trust is listening to each patient's individual needs and establishing an awareness of his or her culture -Performing cultural self-assessment is an integral part of becoming culturally competent -A cultural assessment is an integral part of forming a full database of information about each patient. -Serious errors can occur due to lack of cultural competence. If you fail to ask about traditional, herbal, or folk remedies, you may unknowingly give or prescribe a medication that has a significant interaction. -Ex: ginseng raises the serum digoxin level and can lead to adverse, even fatal, consequences -A key point of understanding cultural diversity is self-awareness and knowledge of one's own culture. Your culture identification might include the subculture of nursing or health care professionals. -To understand another person's culture, you must first understand your own culture

Critical Thinking

-Multidimensional thinking process, not a linear approach to problem solving -Remember to approach problems in a judgmental way and avoid making assumptions

Alcohol

-The most used and abused psychoactive drug -Alcohol use is the 4th leading preventable cause of death in the U.S -An estimated 88,000 people die annually from alcohol-related causes >Alcohol-related driving deaths account for 31% of overall driving fatalities >Emergency department see over 500,000 visits each yr for drugs with alcohol. >For alcohol alone, it is over 800 ED visits for every 100,000 people under 21. -Populations at risk for alcohol abuse: women, older adults, racial/ethnic minorities, and those with lower family income and educational level -Most adults are able to drink low-to-moderate amounts of alcohol safely >Men less than or equal to 2 drinks/day >Women less than or equal to 1 drink/day -This has casual adverse effect on the risk for breast cancer & oral and esophageal cancers -This is dose-dependent; the MORE a person drinks, the HIGHER the risk -Drinking greater than or equal to 30 grams/day (2.1 standard drinks) increases the rate of breast cancer by 32% This is likely due to an increase in estrogen steroids, increasing the risk for hormone-sensitive tumors -Morbidity and mortality data reflect the adverse consequences of alcohol use -A surprisingly high # of prescription meds-591 or 45% are classified as alcohol interactive (AI) >This means that their combination w alcohol changes the metabolism of the alcohol or the activity or metabolism of the medication, with a risk of adverse drug reactions (ADRs) >This is especially significant in drugs that suppress the CNS: opioid pain relievers, heroin, benzodiazepines, antihistamines, antidepressants

Cardiovascular biological mechanisms

-arterial plaque buildup -baroreceptor reflex changes -body fluid changes through renin-angiotensin-aldosterone system -activation of SNS, which constricts blood vessels and increases contractibility

Heavy drinking

-greater than or equal to 15 drinks/week for men -greater than or equal to 8 drinks/week for women -Increases the risk for chronic diseases such as: >Hypertension (men and women consuming more than 1 or 2 drinks a day is associated w hypertension) >Heart disease (heart failure, cardiomyopathy, atrial fibrillation, the most common cardiac arrhythmia) >Stroke (ingestion of more than 2 or 3 drinks increases the risk for all types of stroke) >Breast cancer >Oral & Esophageal cancer >Liver cancer >Colorectal cancer >Depression >Anxiety >Learning & Memory Dysfunction >Social issues such as family problems and unemployment >Alcohol dependence >Alcoholism - Is the major cause of liver cirrhosis, which is the 8th leading cause of death in the US -The latest established casual relationship is between heavy drinking and infectious diseases such as TB and HIV/AIDS -There is NO safe limit of drinking for pregnant women as alcohol drinking causes fetal alcohol syndrome and preterm birth problems

Binge Drinking

-greater than or equal to 5 drinks/occasion for men -greater than or equal to 4 drinks/occasion for women -Increases risk for injuries: >Motor Vehicle Accidents >Falls >Drowning >Burns >Violence (sexual assault, homicide, suicide) >Alcohol poisoning (medical emergency) >Risky sexual behavior (unprotected sex or sex with multiple partners) which increases STDs and unintended pregnancy

AUDIT: Alcohol Use Disorders Identification Test

1. How often do you have a drink containing alcohol? 2. How many drinks containing alcohol do you have on a typical day when you are drinking? 3. How often do you have 5 or more drinks on one occasion? 4. How often during the last year have you found that you were not able to stop drinking once you had started? 5. How often during the last year have you failed to do what was normally expected of you because of drinking? 6. How often during the last tear have you needed a first drink in the morning to get yourself going after a heavy drinking session? 7. How often during the last year have you had a feeling of guilt or remorse after drinking? 8. How often during the last year have you been unable to remember what happened the night before because of your drinking? 9.Have you or someone else been injured because of your drinking? 10. Has a relative, friend, doctor, or healthcare worker been concerned about your drinking or suggested that you cut down? NOTE! The AUDIT covers 3 domains: 1. Alcohol consumption (1-3) 2. Drinking behaviors or dependence (4-6) 3. Adverse consequences from alcohol (7-10) A cut point of greater than or equal to 8 for men or greater than or equal to 4 for women, adolescents, those older than 60 indicates HAZARDOUS alcohol consumption.

4 Factors of Clinical Decision Making

1. Literature Review 2. Patient Preferences 3. Clinical Experience/expertise 4. Physical exam and assessment

7 Categories of Illicit Drug Use

1. Marijuana 2. Cocaine (including crack) 3. Heroin 4. Hallucinogens 5. Inhalants 6. Methamphetamine 7. non-medical use of psychotherapeutics (prescription pain killers, tranquilizers, stimulants, sedatives) abuse of pain relievers is alarmingly high with 17.2% 12 years and older show highest prevalence (10.1%) Marijuana most common used by almost 80% Any amount of illicit drug use has serious legal consequences and consequences for health, trauma, brain maturation, relationships, school, and career

*Nursing Process*

6 phases- assessment, diagnosis, outcome identification, planning, implementation, evaluation 1. Assessment -Collect data >Review of the clinical record >Health history >Physical examination >Functional assessment >Risk assessment >Review of literature -Use evidence-based assessment techniques -Document relevant data 2. Diagnosis -Compare clinical findings with normal and abnormal variation and developmental events -Interpret data >Identify clusters of cues >Make hypotheses >Test hypotheses >Derive diagnoses -Validate diagnoses -Document diagnoses 3. Outcome Identification -Identify expected outcomes -Individualize to the person -Identify expected culturally appropriate outcomes -Establish realistic and measurable outcomes -Develop a timeline 4. Planning -Establish priorities -Develop outcomes -Set timelines for outcomes -Identify interventions -Integrate evidence-based trends and research -Document plan of care 5. Implementation -Implement in a safe and timely manner -Use evidence-based interventions -Collaborate with colleagues -Use community resources -Coordinate care delivery -Provide health teaching and health promotion -Document implementation and any modification 6. Evaluation -Progress toward outcomes -Conduct systemic, ongoing, criterion-based evaluation -Include patient and significant others -Use ongoing assessment to revise diagnoses, outcomes, plan -Disseminate results to patient and family Nursing process is a problem-solving approach The novice nurse has no experience with a specified patient population and uses rules to guide performance. It takes time, perhaps 2-3 years in similar clinical situations, to achieve competency, in which you see actions in the context of patient goals or plan of care With more time and experience, the proficient nurse understands a patient situation as a whole rather than a list of tasks, at this level you can see long-term goals for the patient. The expert nurse has an intuitive grasp of a clinical situation and zeroes in on the accurate solution Intuition: immediate recognition of patterns -Learn to attend to a pattern of assessment data and act w/o consciously labeling it -Knows instant therapeutic responses The method of moving from movie to becoming an expert is through the use of critical thinking

ICU admissions

Alcohol abuse and alcohol withdrawal are involved in trauma, violence, suicides, motor vehicle accidents and other conditions leading to ICU admissions

Developmental Competence: Adolescents

Alcohol consumption decreases/retards brain development and maturity levels in adolescents Associated risk between alcohol use and other high-risk behaviors leading to: -sexual high-risk -academic problems in school -injuries from trauma -continuation of alcohol disease in later life

Health-Related Beliefs and *Practices*

Beliefs About Causes of Illness -Biomedical >Assumes all events in life have a cause and effect >Germ theory: microorganisms such as bacteria and viruses cause specific disease conditions >Most health care providers believe this -Naturalistic >American Indians/Asians >Yin/Yang theory: all aspects of a person are in perfect balance -Balance between the opposing forces -Yin: female, negative forces such as emptiness, darkness, cold -Yang: male, positive, emitting warmth and fullness >Greek humoral theory: regulate basic bodily functions and are described in terms of temp, dryness, and moisture -4 humors -blood -phlegm -black bile -yellow bile -Magicoreligious >Supernatural forces dominate >Ex: voodoo, witchcraft *TRADITIONAL TREATMENTS AND FOLK HEALERS* -Hispanics may rely on curandero(ra), espiritualista (spiritualist), yerbo(ba) (herbalist), or partera (lay midwife). -Blacks may mention having received assistance from a houngan (a voodoo priest or priestess), spiritualist, or "old lady" (an older woman who has successfully raised a family and who specializes in child care and folk remedies). -American Indians may seek assistance from a shaman or a medicine man or woman. -Asians may mention that they have visited herbalists, acupuncturists, or bonesetters. -The Amish the term braucher refers to folk healers who use herbs and tonics in the home or community context. Brauche, a folk healing art, refers to sympathy curing, which is sometimes called powwowing in English. -Many cultures believe that the cure/healing is incomplete unless healing of body, mind, and spirit is carried out. -If your patient refers to a lay healer that you are unfamiliar with ask for clarification. Make sure not to ask in a judgmental way. A wide variety of alternative, complementary, or traditional interventions are gaining the recognition of health care professionals in the biomedical/scientific health care system. Acupuncture, acupressure, therapeutic touch, massage, therapeutic use of music, biofeedback, relaxation techniques, meditation, hypnosis, distraction, imagery, iridology, reflexology, and herbal remedies are examples of interventions that people may use either alone or in combination with other treatments. Many pharmacies and grocery stores routinely carry herbal treatments for a wide variety of common illnesses.

Withdrawal

Cessation of substance produces syndrome of physiologic symptoms

Objective Data

Clinical lab findings (*biomarkers*) give objective evidence of problem drinking These are less sensitive to self-report questionnaires, but they are useful to corroborate the subjective data and are unbiased The serum protein *gamma glutamyl transferase (GGT)* is a commonly used biomarker of alcohol drinking. -Occasional alcohol drinking does NOT raise this measure, but chronic heavy drinking does. Be aware that non-alcoholic liver disease also can increase GGT levels in the absence of alcohol. -NOTE! Chronic alcohol drinking of 4 or more drinks/day for 4-8 weeks significantly raises GGT, but many chronic drinkers no longer have increased GGT -The GGT is helpful in detecting relapses for alcohol-dependent people who are in recovery. -NOTE! A sudden elevated GGT after normal GGT levels may indicate relapse and prompts discussion with person The *carbohydrate-deficient transferrin (CDT)* is used together with GGT, which may increase detection of alcohol abuse. Healthy women have higher CDT levels than men; therefore combining it with GGT may improve accuracy. NOTE! CDT is elevated after drinking 50-80g alcohol/day. CDT normalizes during abstinence with a half-life of 15 days. *Serum aspartate aminotransferase (AST)* is an enzyme found in high concentrations in the heart and liver. -Chronic drinking for months increases AST From the complete blood count, the *mean corpuscular volume (MCV)* is an index of RBC size. MCV is not sensitive enough to use as the only biomarker for problem drinking -Heavy alcohol drinking for 4-8 weeks increases MCV -increased MCV means decreased vitamin B12 A direct serum biomarker, *phosphatidylethanol (PEth)* is a more sensitive and specific method to evaluate abstinence and sober living. *It is the only biomarker that can detect moderate alcohol intake*. PEth is a phospholipid produced only in the presence of alcohol. -PEth elevates after 3 weeks of drinking and remains elevated 14 days after abstinence *Breath alcohol* analysis detects any amount of alcohol in the end of exhaled air following a deep inhalation until all ingested alcohol is metabolized. This measure can be correlated with blood alcohol concentration (BAC) and is the basis for legal interpretation of drinking. Normal value indicating no alcohol is 0. -A BAC greater than 0.08% = legal intoxication in most states (3 standard drinks) with loss of balance and motor coordination.

Collecting Four Types of Data

Complete Total Health Data -Describes current and past health state and forms baseline to measure all future changes -Full interview process -When first admitted to hospital -Complete health history and full physical examination -It yields the first diagnosis -Collected in primary care setting (clinic) -For the well person this database must describe the person's health state; perception of health; strengths or assets such as health maintenance behaviors, individual coping patterns, support systems, and current developmental tasks; and any risk factors or lifestyle changes. -For the ill person the database also includes a description of the person's health problems, perception of illness, and response to the problems. Coll For well and ill people, the complete database must screen for pathology and determine the ways people respond to that pathology or to any health problem. -You must screen for pathology because you are the first, and often the only, health professional to see the patient. This screening is important to refer the patient to another professional, help the patient make decisions, and perform appropriate treatments. This database also notes the human responses to health problems. This factor is important because it provides additional information about the person that leads to nursing diagnoses. Episodic or problem-centered Data -Collect "mini" data, smaller scope and more focused than complete database -Mainly one problem -Ex: 2 days after surgery a hospitalized person suddenly has a congested cough, shortness of breath, and fatigue. The history and examination focus primarily on the respiratory and cardiovascular systems. Ex: Or in an outpatient clinic a person presents with a rash. The history follows the direction of this presenting concern such as whether the rash had an acute or chronic onset; was associated with a fever, new food, pet, or medicine; and was localized or generalized. Physical examination must include a clear description of the rash. Follow-up Data -Status of all identified problems should be evaluated at regular and appropriate intervals -Going to reassess the issue/problem they have/had -What changes have occurred? -Is the problem getting worse or better? -Which coping strategies are being used? -Ex: a patient with heart failure may follow up with his or her primary care practitioner at regular intervals to reevaluate medications, identify changes in symptoms, and discuss coping strategies. Emergency Data -Rapid collection of data often compiled concurrently with lifesaving measures/rapid assessment -Ex: a person is brought into an ED with suspected substance overdose. The first history questions are "What did you take?" "How much did you take?" and "When?" The person is questioned simultaneously while his or her airway, breathing, circulation, level of consciousness, and disability are being assessed. -Once the person has been stabilized, a complete database can be compiled.

Chapter 1

Evidence-Based Assessment

Chapter 2

Cultural Assessment

Culture-Related Concepts

Culture is a complex phenomenon that includes: -Attitudes -Beliefs -Self-definitions -Norms -Roles -Values Much of culture is transmitted non-verbally through socialization or enculturation -Socialization/enculturation: process of being raised within a culture and acquiring the norms, values, and behaviors of that group A person's culture defines health and illness, identifies when treatment is needed and which treatment are acceptable, and informs a person of how symptoms are expressed and which symptoms are important 4 Basic Characteristics of Culture 1. Learned from birth through the processes of language acquisition and socialization 2. Shared by all members of the same cultural group 3. Adapted to specific conditions related to environmental and technical factors and to the availability of natural resources 4. Dynamic and ever changing -*Ethnicity* refers to a social group that may possess shared traits, such as a common geographic origin, migratory status, religion, language, values, traditions or symbols, and food preferences. -Ethnic identity: one's self-identification with a particular ethnic group -Acculturation: person adapts & changes a bit to fit majority but they don't lose original cultural identity -process of adopting the culture and behavior of the majority culture -those who emigrate find the process of acculturation in schools or society extremely difficult -Assimilation: unidirectional in single fashion -minority culture is fully absorbed into majority culture -immigrants were discouraged from having a unique identity in favor of the nationalist identity -The process of taking on the characteristics of a culture by giving up one's own Biculturalism and integration: Allow for reciprocal change and maintaining ethnic identity Acculturative stress: Based on input from the environment, social/interpersonal and societal -The losses and changes that occur when adjusting to or integrating a new system of beliefs, routines, and societal roles are known as acculturative stress

*CAGE questionnaire* Know what does it stand for?

Cut down Annoyed Guilty Eye opener -works well in primary are settings because it takes less than 1 minute to complete and the 4 straightforward yes/no questions -for lifetime alcohol abuse and/or dependence but does not distinguish past problem drinking from active present drinking -it may not detect low but risky levels of drinking and is less effective w women and minority groups

Abuse

Daily use needed to function, inability to stop, impaired social and occupational functioning, recurrent use when it is physically hazardous, substance-related legal problems

Assessing Homicide Risk

Danger Assessment (DA) -this 19-item yes/no instrument is used extensively by nurses in the health care system -it starts with a calender so women can more accurately see how frequent and severe violence has become over the past year -this is also an excellent assessment of frequency and severity of violence for health care providers -the more yes answers, the more serious danger of the women's situation

Subjective Data

Data collected by examiner asking questions - If patient is currently intoxicated or going though substance withdrawal, collecting any history data is difficult and unreliable - However, when sober, most people are willing and able to give reliable data, provided that the setting is private, confidential, and non-confrontational

Diagnostic Reasoning

Diagnostic reasoning: the process of analyzing health data and drawing conclusions to identify diagnoses Novice nurses most often use a diagnostic process involving hypothesis forming and deductive reasoning -Hypothetico-deductive process 1. Attending to initially available cues 2. Formulating diagnostic hypotheses 3. Gathering data relative to the tentative hypotheses 4. Evaluating each hypothesis with the new data collected, thus arriving at a final diagnosis

Cultural Sensitivity

Explore your own personal history so as to develop cultural sensibility. -Use thoughtful reasoning. -Responsiveness -Discrete interactions Think about the components of culture that you experience in your own daily life. -Purposely action to gain better understanding so as to help others -Only when we acknowledge our own values and beliefs are we able to fully help others.

*Priority Problems Level*

First-level priority -Emergent, life-threatening, and immediate -ABCs -Ex: Establishing an airway or supporting breathing Second-level priority -Those next in urgency -Those requiring your prompt intervention to forestall further deterioration -Ex: Mental status change, Acute pain, Acute urinary elimination problems, Untreated medical problems, Abnormal lab values, Risks of infection, Risk of safety or security Third-level priority -Important to patient's health but can be attended to after more urgent health problems are addressed -Interventions to treat these problems are long-term -The response to treatment is expected to take more time -May require a collaborative effort between the patient and health car professionals -Ex: Lack of knowledge, Mobility problems, Family coping Collaborative problems -Consult other practitioners as appropriate to care for your patients -Once you have determined problems, you must identify expected outcomes and work with the patient to facilitate outcome achievement

How to Assess for Intimate Partner Violence

Gathering subjective data -Use of open-ended questions to start the conversation >"Tell me what happened" -Interview the individual separately from the perpetrator -Listen for cues which may indicate a pattern or responses that don't match the "physical" injury that is present -Be aware of state laws and requirement to report -You don't need to prove the abuse in order to file a report

Diagnosing Substance Abuse

Gold standard of diagnosis is well defined in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) - Alcohol problems under-diagnosed both in primary care settings & in hospitals - Excessive alcohol use often unrecognized until patients develop serious complications *Lot of people -The use of alcohol and other drugs activates reward circuits in the brain by releasing dopamine, and the users feel pleasure -With continued use, the reward circuits are desensitized, pleasure is no longer felt, and the user feels less motivation to engage in everyday activities -The conditioned response (environmental cues that precede drug use) become more important, leading to cravings for alcohol and other drugs -Continued used leads to brain changes involved in executive function (decision making, control of inhibition, self-monitoring), and repeated relapse occurs -Not all drug use lead to addiction; although it is a brain disease, it influenced by genetic, environmental, and developmental factors -Alcohol dependence, or alcoholism, is a chronic progressive disease that is not curable but is highly treatable

The Joint Commission

Has set standards that all health care settings have policies and procedures to assess, document, and make referrals for family violence, including intimate partner abuse, child abuse, and elder abuse

Assessment of Child Abuse and Neglect

Health care providers -provide anticipatory guidance -ideal individual to able to monitor, observe, and assess for potential problems Use appropriate resources to educate -developmental screening tools (normal period of excessive crying from infant) -parent/caregiver teaching and education Medical history is important part of exam If child is verbal, history should obtained away from caregivers through open-ended questions or spontaneous statements If child is non-verbal subjective data will come from caregiver. Be attentive to interaction between caregiver and child. Remember the possibility that the abuser may be accompanying the child When documenting history and physical findings of child abuse and neglect: use words child has used to describe how his or her injury ocurred Know hospital protocol, some may delay a full interview until it can be done by a forensically trained interviewer

Cultural Assessment

Heritage. Country of ancestry; years in the United States, etc. • Health practices. Use of a traditional healer; complementary/alternative therapies; preventative medicine; any practices that are unacceptable (e.g., blood transfusion) • Communication. Primary language; preferred name and method of communication; use of touch as a communication strategy • Family roles and social orientation. Who makes health care decisions within the family; family priorities; role of extended family; relationship status • Nutrition. Any forbidden foods; fasting rituals; foods avoided or consumed during illness and in the peripartum period • Pregnancy, birth, child-rearing. Number of children in the family; beliefs surrounding pregnancy; beliefs surrounding childbirth and child-rearing; special rituals after delivery • Spirituality/religion. Religious affiliation; religious beliefs; holidays; spirituality assessment • Death. Rituals in preparation for death; meaning of death; grieving • Health providers. What is the role of the nurse or doctor; preference for same sex provider; any healers besides physicians and nurses There is no one universally accepted tool that addresses all variables Do NOT stereotype but listen and learn

Expanding the Concept of Health

Holistic Model Assessment -Incorporation of impact of external and interpersonal environment on one's mind and body or the whole person -Holistic health views the mind, body, and spirit as interdependent and functioning as a whole within the environment -Both the individual human and the external environment are open systems, dynamic and continually changing and adapting to one another. -In a holistic model, assessment factors are expanded to include such things as lifestyle behaviors, culture and values, family and social roles, self-care behaviors, job-related stress, developmental tasks, and failures and frustrations of life. Health Promotion and disease prevention -Guidelines to prevention emphasize the link between health and personal behavior -"The Guide to Clinical Preventative Services": annual update as an approach to health and risk reduction -Prevention can be achieved through counseling from primary care providers designed to change people's unhealthy behaviors related to smoking, alcohol and other drug use, lack of exercise, poor nutrition, injuries, and sexually transmitted infections -Health promotion is a set of positive acts that we can take. In this model the focus of the health professional is on teaching and helping the consumer choose a healthier lifestyle. Culture and Genetics -Awareness of the emerging minority (African americans, Latinos, Asian americans) -Diversity and incorporation of "cultural health rights"

Abnormal Findings

Immersion Injury Patterns A, Immersion in hot water; note sparing of the flexor creases. B, Immersion stocking burn of an infant's foot. C, Immersion glove burn of an infant's hand. D, Immersion buttocks burn. Pattern Burn Injury A, Hair straightening iron burn on the buttocks. B, Burn caused by a steam iron. C, Burn caused by fork tines. D, Burn caused by a lighter. Cigarette Burns These burns demonstrate classic abuse with lesions in various stages of healing Abusive bruise on the left cheek demonstrates the imprint of fingers Belt Loop Bruising in the pattern of a belt loop Bruising and Petechiae Bruising and petachiae of the pinna area postauricular area consistent with a hand slap Thigh Bruises Inner thigh bruises on a woman with severe dementia. The placement of bruises is suspicious for sexual abuse. Defensive Wounds Defensive wounds are often found on the hands and forearms as the victim tries to protect his or her body from the assailant. Nasal Fracture Periorbital ecchymoses and fracture nasal bone. Pressure Ulcers

Intimate Partner Violence (IPV)

Includes both current and former partners, so the person need not currently be in a relationship to experience intimate partner violence Divided into 4 categories 1. *Physical violence*: the use of force that could cause death, disability or injury 2. *Sexual violence*: includes any attempted or completed sex acts without the consent of the other person. Acts of sexual violence include, but are not limited to, rape, unwanted sexual conduct, and exposure to sexual situations (porn) 3. *Stalking*: repeated, unwanted attention that leads to fear (e.g., repeated phone calls, spying, damaging personal property) 4. *Psychological Agression*: is a form of emotional abuse wherein the aggressor uses verbal or nonverbal communication to exert control or harm the person emotionally Includes *teen dating violence*: -physical, sexual, psychological, or emotional violence that occurs in dating relationship during the adolescent years -youth who experience dating violence are more likely to experience depression or anxiety, to engage in unhealthy behaviors (smoking, alcohol use), and to have thoughts about suicide -it is important to note that, with advances in technology, new types of relationship violence are emerging, such as "sexting" or cyber abuse, which can be perpetuated 24/7 from a distance

Prescription Drug Abuse And Opioid-Related Deaths

Increased rate of deaths from drug overdose as opposed to motor vehicle accidents Contributing factors to Rx abuse and Opioid crisis: -increase in Rx for pain medication -Marketing strategies to promote activities -Misrepresentation of "addictive" nature -Combination addictions- drinking and taking alcohol-interactive medications

Intoxication

Ingestion of substance produces maladaptive behavioral changes because of effects on the CNS

Evidence-Based Practice

Integration of 1. Research evidence 2. Clinical expertise 3. Clinical knowledge (physical assessment) 4. Patient values and preferences Basically same as Clinical Decision Making: 1. Best evidence from literature review 2. Patient's own preferences 3. Clinician's experience/expertise 4. Physical exam EBP is more than the use of best-practice techniques to treat patients. EBP is MULTIFACETED and reflects HOLISTIC CARE Although assessment skills are foundational to EBP, it is important to question tradition when no compelling research evidence exists to support it! Ex: At first they would aucultate bowel sounds after surgery to hear returning GI motility but this was a poor indicator, instead they researched and found that the return of flatus and the first post-operative bowel movement to be more suggestive of GI motility. Takes long for research to be implemented into action but it is important for students and nurses to study EBP so they can discern which interventions would best serve their individual patient

Opiates (morphine, heroin, meperidine) Intoxication and Withdrawal

Intoxication -Appearance >PINPOINT PUPILS >DECREASED BP, PULSE, RESP, TEMP -Behavior >LETHARGY >SOMNOLENCE >slurred speech >initial euphoria followed by apathy >dysphoria >psychomotor retardation >inattention >impaired memory >impaired judgment >impaired social or occupational functioning Withdrawal -DILATED PUPILS -LACRIMATION -RUNNY NOSE -TACHYCARDIA -FEVER -ELEVATED BP -PILOERECTION -sweating -diarrhea -yawning -insomnia -restlessness -irritability -depression -nausea -vomitng -malaise -tremor -muscle and joint pain -symptoms remarkably similar to clinical picture of influenza

Alcohol Intoxication and Withdrawal

Intoxication -Appearance >Unsteady gait, incoordination, nystagmus, flushed face -Behavior >Sedation, relief of anxiety, dulled concentration, impaired judgment, expansive, uninhibited behavior, talkativeness, slurred speech, impaired memory, irritability, depression, emotional lability Withdrawal -Uncomplicated >Shortly after cessation of drinking, peaks at 2nd day, improves by 4th or 5th day >Coarse tremor of hands, tongue, eyelids >Anorexia >Nausea/vomiting >Malaise >Autonomic hyperactivity (tachycardia, sweating, elevated BP) >Headache >Insomnia >Anxiety >Depression or irritibility >Transient hallucinations or illusions -Withdrawal delirium >"delirium tremens" >Much less common than uncomplicated, occurs within 1 week of cessation >Coarse, irregular tremor >Marked autonomic hypersensitivity (tachycardia, sweating) >Vivid hallucinations >Delusions >Agitated behavior >Fever

Cocaine (Crack) Intoxication and Withdrawal

Intoxication -Appearance: >Pupillary dilation >Tachycardia or bradycardia >Elevated or lowered BP >Sweating >Chills >Nausea/vomiting >Weight loss -Behavior >Euphoria >talkativeness >Hyper-vigilance >pacing >Psychomotor agitation >Impaired social or occupational functioning >Fighting >Grandiosity >Visual or tactile hallucinations Withdrawal -Dysphoric mood: >Anxiety >Depression >Irritability -Fatigue -Insomnia or hyperinsomnia Psychomotor agitation

Elder Abuse and Neglect

Involves both intentional and failure to act by caregiver or trusted person -underreported with 60% performed by a family member Forms of elder abuse: *Physical abuse*: is when an elder is intentionally injured, assaulted, threatened with a weapon, or inappropriately restrained *Sexual abuse or abusive sexual contact*: any sexual contact against the elder's will, including sexual contact with a person unable to understand the act or communicate consent *Psychological or emotional abuse*: includes verbal and non-verbal behavior meant to inflict fear or distress. It includes humiliation, embarrassment, controlling behavior, social isolation, and damaging/destroying property *Neglect*: failure of the caregiver to prevent harm. Includes failure to meet basic needs such as hygiene, nutrition/hydration, clothing, shelter, and medical care *Financial abuse or exploitation*: unauthorized or improper use of the elder's resources for monetary or personal benefit, profit, or gain, such as forgery, theft, or improper use of guard ship or power of attorney (Ask what's going on at home, who takes care of finances?) -You need to be familiar with the reporting requirements in the state in which you practice! -In some communities, you report county by county or others there's a statewide hotline -If you work in a state that's border between two states, then you would report to both states -As mandatory reporters of abuse, you need only have suspicion that elder abuse and/or neglect may have occurred to generate a call to the authorities, you are not required to have proof before reporting suspected abuse

Assessment for Intimate Partner Violence

It is important you normalize the questions by asking every pt about IPV. While women are at a higher risk for IPV, men are also victims of abuse History questions including prior hospitalizations, treatment for injuries, delayed treatment, may give some cues especially if the person has been injured multiple times. Make sure the circumstances the person seeking care states matches the type of damage "Do you feel safe at home?" USPTF prefers standardized tools >HITS: 4-item tool that asks clients to answer the following questions from never to frequently 1. Physically hurt you 2. Insult or talk down to you 3. Threaten you with harm 4. Scream or curse at you -Can also be used to screen teen dating violence (make sure to use age-appropriate language and provide examples; all teens who come with an injury must be screened) -If one answer if yes, its a positive screening >STaT: 3-item tool that includes the following questions 1. Have you ever been in a relationship where your partner pushed or *slapped* you? 2. Have you ever been in a relationship where your partner *threatened* you with violence? 3. Have you ever been in a relationship where your partner has *thrown*, broken, or punched things? -If one answer if yes, its a positive screening

The nurse is assessing a patient who has been abusing opiates for 4 years. The patient says, "I can quit anytime I want" The nurse should interpret this statement to be a sign that this individual

May be in denial of needing help or having a problem with opiates

Critical Thinking and the Nursing Process: Nursing Judgment Nursing levels

Novice -Starting out in an area of learning -Uses rules to guide performance -Initial available cues from assessment data Competency -Building on 2-3 years of clinical experience -See actions in the context of patient goals or plans -Cluster cues Proficient -Adding to time and experience -Understands the patient situation as a whole rather than individual parts -Apply long-term goals Expert -Attained mastery of an area of learning -Clinical judgment -Intuitive analysis and rapid recognition of causal or associated cues to solve problems

Assessment of Older Adult Abuse and Neglect

Older adult as a vulnerable population -Recommend routine screening by multiple agencies but no specific tool recommended -Assessment of abuse or neglect in cognitively challenged persons is complicated Older adult abuse Suspicion Index -Validated in primary care -For use in cognitively intact patients -Includes 6 questions with 5 questions asked of the patient and the last question answered by the physician Note any hand prints, bruising between thighs, look at clotting Note: also be aware of financial abuse!

Documentation: IPV, Child Abuse, or Older Adult Abuse

Provide detail -Non-biased progress notes, injury maps, and photographic evidence Transcribe verbatim!!!!! -Information received from individual verbatim because they will use the information in court, so write word for word what they say -If you are unsure what the person means, ask for clarification Physical Exam -Through documentation using forensic technology terms -Thorough and unbiased -Do not speculate on what caused an injury, instead document what you observed and what the victim said Provide digital photographic documentation in the medical record -Obtain consent May have to separate -The pt from the parent, spouse, and/or caregiver-follow protocol

Tolerance

Requires increased amount or substance to produce same effect

A nurse working in the emergency department triage wants to apply principles of priority setting with regard to an organizational framework for delivery of care. Based on your understanding of the principles of priority setting, what categories would be included in the framework?

Setting priorities is a dynamic, changing process. The categories are as follows: First-level priority Second-level priority Third-level priority

AUDIT-C

Shorter version of AUDIT for acute and critical care units - screening test for heavy drinking and/or active abuse Score: 3 or above = heavy or at-risk drinking

Determinants of Health and Health care Disparities

Social Determinants of Health (SDOH) -An individuals's health status is influenced by a constellation of factors known as SDOH -Include: >Economic stability >Education >Social and Community context >Neighborhood and built environment >Health and Health care -The five social determinants of health are interconnected and affect a person's health from preconception to death. However, evidenced-based research has consistently shown that *poverty* has the greatest influence on health status. - Public health sectors must be encouraged to address the needs for safe and affordable housing; reliable transportation; nutritious food that is accessible to everyone; safe, well-integrated neighborhoods and schools; health care providers that are culturally and linguistically competent; and clean water and air

Religion and Spirituality

Spirituality: broader term focused on a connection to something larger than oneself and a belief in transcendence Religion: an organized system of beliefs concerning the cause, nature, and purpose of the universe, as well as the attendance of regular services Two concepts that can be interrelated but do not have to exist simultaneously Individuals define their feelings and beliefs Although fewer individuals identify with a specific religion, spirituality assessment is important for all patients regardless of religious affiliation or non-affiliation In times of crisis such as serious illness and impending death, spirituality may be a source of consolation for the person and his or her family Religion and spirituality are associated with improved physical health, and attending to the religious needs of patients is an important part of holistic patient care

Screening Aging Adults: SMAST-G

Stands for Short Michigan Alcoholism Screening Test Use the SMAST-G questionnaire for older adults who report social or regular drinking of any amount of alcohol Older adults have specific emotional responses, and physical reactions to alcohol, and the 10 questions with yes/no responses address these factors. A low-risk is a zero or 1 pt. Scoring 2 or greater indicates an alcohol problem and a need for more in-depth assessment. When talking with others, do you ever underestimate how much you drink? Does having a few drinks help decrease your shakiness or tremors? Does it help to relax or calm your nerves? Have you ever increased your drinking after experiencing a loss in your life? When you feel lonely, does having a drink help?

Chapter 6

Substance Use Assessment

Evidence-Based Assessment Practice History

The conviction that all patients deserve to be treated with the most current and best-practice techniques led to the development of *evidence-based practice (EBP)*. As early as the 1850s Florence Nightingale was using research evidence to improve patient outcomes during the Crimean War. It was not until the 1970s, however, that the term *evidence-based medicine was coined*. The CONCEPT of EBP began with Nightingale! In 1972 a British epidemiologist and early proponent of EBP, Archie Cochrane, identified a pressing need for systematic reviews of *randomized clinical trials*. In a landmark case, Dr. Cochrane noted multiple clinical trials published between 1972 and 1981 showing that the use of corticosteroids to treat women in premature labor reduced the incidence of infant mortality. A short course of corticosteroid stimulates fetal lung development, thus preventing respiratory distress syndrome, a serious and common complication of premature birth. Yet these findings had not been implemented into daily practice, and thousands of low-birth-weight premature infants were dying needlessly. Following a systematic review of the evidence in 1989, obstetricians finally accepted the use of corticosteroid treatment as standard practice for women in preterm labor. Corticosteroid treatment has since shown to reduce the risk of infant mortality by 30% to 50%

Health Care Disparities

These people are vulnerable populations and include ethnic and racial minorities, people with disabilities, and the LGBT community. Ex: African-American children twice as likely to be hospitalized and four times likely to die from asthma than non-Hispanic whites Ex: Infant mortality rate for African-Americans is double that of overall US (10 vs 5) Ex: 30% of Hispanics and 19% African-Americans do not have health insurance Ex: African-American women die more during child-birth -Goal of "Healthy People" is to eliminate health disparities -A health disparity is a "particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage" Promoting of health care Frameworks -Accessible, culturally and linguistically competent delivery of health care to promote quality of life -Many forms of discrimination based on race or national origin limit the opportunities for people to gain equal access to health care services. -Language barriers have a negative impact on the quality of care provided, and those patients with language barriers also have increased risk of noncompliance to treatment regimens. -Because immigration occurs at high levels and immigrants with limited English proficiency (LEP) have particular needs, the Office of Minority Health published "the National Standards for Culturally and Linguistically Appropriate Services in Health Care". This set of 15 standards provides a blueprint to improve the quality of care and eliminate health disparities for culturally diverse populations. -Under the provisions of Title VI of the Civil Rights Act of 1964, when people with LEP seek health care in settings such as hospitals, nursing homes, clinics, daycare centers, and mental health centers, services cannot be denied to them.

Transcultural Expression of Illness

Transcultural expression of pain -Expectations, manifestations, and management of pain are all embedded in a cultural context. -Pain has been found to be a highly personal experience, depending on cultural learning, the meaning of the situation, and other factors unique to the person. -!!!Silent suffering has been identified as the most valued response to pain by health care professionals.!!!

Routine Screening for Intimate Partner Violence (IPV)

US Preventative Task Force Guidelines (USPTF) -all women of childbearing age (14-46) should be screened (YOU SHOULD ASK MEN TOO) -screening should take place regardless of whether the person has signs of abuse or neglect -no current recommendation for children screening for abuse :( Early detection is the key in terms of prevention of long-term complications Health care providers are mandatory reporters

Spiritual Assessment

Use open-ended questions to start the conversation -"Do you have any religious or spiritual preferences that we can support"? Variety of tools available - FICA—Faith, importance/influence, community and address/action -Brief R-COPE—examines patient's coping mechanisms

Objective Data: Clinical Institute Withdrawal Assessment (CIWA)

Used when caring for people experiencing alcohol withdrawal Most sensitive scale for objective measurement It is quantified to measure the progress of withdrawal Avoids advanced withdrawal stages such as delirium tremens Most withdrawing persons do not progress to advanced stages; thus using the CIWA scale also avoids overmedicating Take vitals!!!; blood pressure, pulse, respirations, oxygen saturation. Assess and rate each of the 10 criteria of the CIWA scales. Individual subscales include 7 criteria with the exception of Orientation which includes 4 criteria Based on continued assessment provides trended results to determine level of monitoring that is needed. >Score of 0-7 can monitor every 4 hrs >Score of below 8 for 72 hrs, you can discontinue

Becoming a Culturally Competent Practitioner

• Culturally sensitive implies that caregivers possess some basic knowledge of and constructive attitudes toward the diverse cultural populations found in the setting in which they are practicing. • Culturally appropriate implies that the caregivers apply the underlying background knowledge that must be possessed to provide a given person with the best possible health care. • Culturally competent implies that the caregivers understand and attend to the total context of the individual's situation, including awareness of immigration status, stress factors, other social factors, and cultural similarities and differences Cultural care -Provision of health care across cultural boundaries in consideration of context