NU 3600 Exam III: Global Health I&II and Disaster Care I&II

Response: The Second Component of the Disaster Management Cycle

-Level of Disaster -Federal response plan -Response to bioterrorism -http://www.fema.gov/

Incident Command System (ICS)

"When things are lost, disasters are measured in dollars. When people are killed, distant observes rate the toll in the number of lives lost." (Pigott)

Disaster Management Cycle: Stage I Prevention (includes Mitigation & Protection)

*"Failure to Prepare is Preparing for Failure"* *Prevention (Mitigation & Protection)* -The cornerstone of emergency management -*"The ongoing effort to lessen the impact disasters have on people's lives and property through damage prevention and flood insurance" (FEMA, 2009)* -Measures such as: building safely within the floodplain or removing homes altogether; engineering buildings and infrastructures to withstand earthquakes; creating and enforcing effective building codes to protect property from floods, hurricanes and other natural hazards -The impact on lives and communities is *lessened*

What Can You Do to TREAT Patients in Response to a Traumatic Event?

*(Requires preparation, sensitivity, assertiveness, flexibility & common sense)* Provide education to help people identify symptoms of anxiety, depression, and PTSD Offer clinical follow-up, including referrals to mental health professionals who have experience treating survivors of traumatic events

Review: Mitigation

*All-hazards mitigation* (prevention) is an emergency management term for *reducing risks to people and property from natural hazards before they occur.* Prevention against natural disasters: -*Structural and non-structural* measures Prevention against man-made disasters: -Include heightened inspections; improved surveillance and security operations; -Public health and agricultural surveillance and testing; immunizations; isolation; or quarantine and halting of human- made threats.

How Do You INTERACT with Patients after a Traumatic Event?

*Be alert to their various needs* (medical, physical, emotional) *Listen and encourage patients to talk* about their reactions when they feel ready. Validate their emotional reactions. *Intense, painful reactions are common responses* Communicate, *person to person* rather than "expert" to "victim," using straightforward terms.

Common Responses to a Traumatic Event [Table 23-2, pp. 518]

*Cognitive* -poor concentration -confusion -disorientation -indecisiveness -Shortened attention span -memory loss -unwanted memories *Emotional* -Shock -Numbness -Feeling overwhelmed -Depression -Feeling lost -Uncertainty of feeling -Volatile emotions *Physical* -Nausea -Light-headedness/dizziness -GI problems -Rapid HR -Tremors -HAs -Fatigue -Poor sleep -Pain -Hyperarousal -Jumpiness *Behavioral* -Suspicion -Irritability -Argumentative -Withdrawal -Excessive silence -Inapp humor -Increased/decreased eating -Increase smoking or substance use/abuse

Compare and Contrast: Developed vs Less developed countries

*Developed Countries*: more technology and economically advanced -Healthcare is available to everyone -Reduction of infant mortality -Nurses can play an important role in care -Financing is done by private and governmental means *Less Dev Countries*: striving for greater economic and technological growth -No healthcare coverage -High infant mortality -Higher incidence of communicable diseases -Lack of knowledge -Minimal nurses -Lack of economy

Major Global Health Problems: Global Burden of Disease & Concerns over GBD

*Global Burden of Disease (GBD)*: Combines losses from premature death and losses of healthy life that result from disability (Stanhope & Lancaster, 2oo8) A single measure of disease burden for the GBD is called *Disability-Adjusted Life Years (DALYs)* -Ex of DALY Conditions: Lower respir infxns, Ischemic HD, Stroke, Diarrheal dx, preterm birth complications, HIV/AIDS, COPD, road injury, DM, TB *Concerns over GBD* -People can no longer contribute to the family's or community's economic growth -Tremendous loss of human potential from childhood deaths -*What is the impact of AIDS? Maternal and infant mortality? Diarrhea?*

HC Reform Plan in China (2009)

*Healthcare Reform Plan (2009)* -Today health care is managed by *Ministry of Public Health* -Goal: Develop a system of health insurance to help people pay for catastrophic illness, increase and improve education for nurses, develop urban health centers -90% coverage by 2011; 100% by 2020 -Goal: Provide basic health care as a public service *Nursing Roles* -Nursing education programs were terminated then re-established in the 80s -Image of nursing is improving (i.e. SARS, Sichuan earthquake) -Nurses pay and working conditions are factors in nurses leaving China (similar to CNA in US; doctors similar to RN salary in US)

Major Global Health Problems: Natural and Man-made Disasters

*Natural disasters* Earthquakes Floods Droughts Tsunamis Hurricanes *Man-made disasters* Bioterrorism Pandemics Genocide

Types of Disasters

*Natural* Hurricanes, tornadoes, floods, earthquakes, tsunamis, avalanches... Example: Super Storm Sandy *Societal (human-made)* War, bioterrorism, fire, transportation accidents

The Role of Population Health

*Population health refers to the health outcomes of a group of individuals, including the distribution of such outcomes within the group, and includes health outcomes, patterns of health determinants, and policies and interventions that link these two* Focuses on the broad range of factors and conditions that have a strong influence on the health of a population (environment, genetics, ethnicity, pollution, and physical and mental stressors affecting a community) Emphasizes health for groups as opposed to the individual Focus on reducing inequities, improving health in these groups to reduce morbidity and mortality, and assessing emerging diseases and other health risks to the community

Role of PHN in Disaster Recovery

*Psychosocial support* -Acute and chronic illnesses become worse by the prolonged effects of disaster. -Feeling of severe hopelessness, depression, and grief in the disillusionment phase. -Majority of individuals will eventually recover from disasters but *mental distress may persist for months to come*

Local Preparedness

*Public Health Preparedness Program Coordinator | Milwaukee/Waukesha County Consortium for Emergency Public Health Preparedness* "Before, during, and after an incident, members of at-risk populations may have additional needs in one or more of the following functional areas:communication, medical care, maintaining independence, supervision, and transportation." (DHHS) *Review: Who is most vulnerable?* Seniors Vision and/or hearing impaired Women Children Indiv w/chronic dx Indiv w/chronic mental illness Non-English-speaking Low income Homeless Tourists; ppl new to area Ppl with disabilities Single-parent families Substance abusers Undocumented residents

How Disasters Affect Communities

*Stress reactions in individuals* -Table 23-3 (p. 522) lists symptoms that may require assistance -Exacerbation of a chronic disease; ex: DM and BS levels -Older adults' reactions dependent on health, strength, mobility, independence, and income -Children: esp disruptive; may respond with regressive behaviors, like thumb-sucking, bedwetting, crying, clinging to parents *Stress reactions in the community* 1. Heroic: exhaustion, overworked to help 2. Honeymoon: survivors rejoice (1&2 most often associated with response efforts) 3. Disillusionment: occurs as time elapses and ppl notice add'l help and reinforcement are not coming as quickly as initial response 4. Reconstruction: longest phase; rebuild and reestablish community, return to new state of normalcy (3&4 linked with recovery)

HC in The Netherlands [EXAM III: Choose two countries: know one strength and one weakness and how it's financed; will have to write about one but know two jic]

-2006, Health policy reform - Residents required to purchase health insurance, which is provided by private health insurers that compete for business -Insurers required to accept every resident in their coverage area regardless of preexisting conditions -Government provides larger subsidies to insurers for participants who are sicker, elderly, or have preexisting conditions -Tax credits given to low-income clients to help them purchase insurance -Everyone with the same policy pays the same premium -Children under 18 are insured at no cost

United Nations Children's Fund (UNICEF)

-Advocate for health needs of women and children under 5 -Provides emergency food and healthcare to all children -Provides long-term humanitarian services -Advocate for safe drinking water, education, and sanitation

The Pan American Health Organization (PAHO)

-An international public health agency with 100 years (1902) of experience working to improve health and living standards of the people of the Americas. -Part of the United Nations system -Regional Office for the Americas of the World Health Organization

HC in Ecuador

-Both public sector and private sector -Public sector - provides health care services to the whole working and uninsured populations. -Private sector - Insurance for the middle and high income groups (about 3% of population) -Special government services that provide nutrition for the poor and maternity services: benefit -Greatest perk for foreign residents: high quality, low cost health care -More personal attention from medical practitioners than in the US -State of the art equipment and specialist in all fields in the bigger cities

Disaster Facts

-Can affect one family at a time or can affect millions of people -American Red Cross responds to a disaster in the United States every 8 minutes (over 70,000 incidents each year) -Number of reported natural and human-made disasters continues to rise worldwide *Number of lives lost has *decreased*, but number of people affected has *increased* -Disaster *disproportionately strikes at-risk* individuals -Monetary cost of disaster recovery efforts *have risen*

What Can You Do to HELP Patients COPE with a Traumatic Event?

-Explain that symptoms may be normal -Identify concrete needs and attempt to help (e.g., How do I know if my friends made it to the hospital?) -Keep to their usual routine -Help identify ways to relax. *Encourage talking about their experiences and feelings with friends, family, or other support networks*

HC in Mexico

-Fractionalized system with a variety of public programs -No universal coverage, only employed covered by a social security-administered system -Private insurance mostly used by the wealthy -Seguro Popular program (2003) created to help cover more of the uninsured population -Social security system - broad coverage for medical services -Seguro Popular program provides access to an established set of essential medical services and drugs needed -Half of funding comes from out-of-pocket payments -Funding from general taxes, payments from employers

Homeland Security: Policy Overview

-Homeland Security Act of 2002 -National Preparedness Guidelines (NPG) -National Incident Management System (NIMS) -HSPD-21: Public Health and Medical Preparedness and the National Health Security Strategy (NHSS) -Pandemic and All-Hazards Preparedness Act (PAHPA)

What can Community Health Nurses Do? [*KNOW FOR EXAM 3*]

-Integrate concepts of health/disease to individuals and aggregates -Understand relationship between personal and environmental factors that affect health -Build partnerships with communities -Participate in policy making at all levels -*Educate the public* -*Learn about and become involved in organizations that shape international agendas* -*Acquire deliberate experiences that raises appreciation for other cultures* -*Embrace diversity*

HC in China

-Many public health advances (controlling contagious diseases, reducing infant mortality rates, etc.) -Use of traditional and Chinese medicine -Developed "one child per family" policy in the 1980s -Large number of nurses, but larger number of doctors -Socialistic system described as "Collective" The common good for all people *Collective System* -Financed through cooperative insurance plans -Owned and controlled by the state and used "Barefoot Doctors" -Government stressed improvement in water quality, disease prevention, and implemented massive public health campaigns

World Bank

-Mission - A world free of poverty -Aim is to improve the health status of individuals in areas that lack economic development -Its primary focus is helping the poorest people and the poorest countries (worldbank.org) -Gives loans to less developed countries -http://worldbank.org/

HC in Uganda

-National service - health care is supposed to be free and accessible to all -Five clinic and hospital facilities that patients can access (Level I-IV clinics) -Often units do not have the essential drugs that patients need -Faith based hospitals -Private medical practices/clinics set up by individual doctors or nurses as an income generator for themselves -Traditional healers (herbal therapy, magic, bloodletting) often cause more harm than good -Weakness: often run out of medications, no made of clinic; like asthma inhalers

Review: Nursing Activities

-Prevention, Preparedness -Response, Recovery -Review Ch. 23, S&L, Boxes, Tables, Key Points -Activity: explore variety of disasters, resources. Preparing and getting trained: seniors, terrorism, fires, flu -Emergency Preparedness Fast Facts/ Red Cross

Disaster Management Cycle: Stage IV: Recovery

-Recovery is about returning to the new normal, a community balance of infrastructure and social welfare that is near the level that it would have had if the event had not occurred. -The recovery phase is *often the hardest part of a disaster*. -For large scale events, federal government provides assistance with rebuilding and restoring. -Shift from short-term aid to long-term support for communities: sustainment of effort.

World Health Organization (WHO)

-Special health agency created to address the wide scope and nature of the world's health problems *Three Major Divisions:* 1. *The World Health Assembly*: Approves the budget and makes decisions about health policies 2. *The Executive Board*: Serves as a liaison between the assembly and the secretariat The Secretariat: Carries out the day-to-day activities of the WHO 3. *Principal Work*: Direct and coordinate international health activities and to provide technical medical assistance to countries in need

HC in the United Kingdom

-Tax-supported health system owned and operated by the government -Services available to all citizens without cost or for a small fee: benefit -Administration of health services conducted through system of health authorities called Trusts -Comprehensive services (general medicine, disability, and rehabilitation, surgery) offered by Trusts -Physicians paid by number of clients they serve, not by individual visits: negative, discourages f/u visits -Individuals maintain high level of support for government funding and control of their health services: benefits -Public health nurses (i.e. elderly and new mothers) -Reduction in infant mortality rates (1975-2002) -Increased life expectancy -Skyrocketing costs over the past decades -Weakness: Very long waiting list ex open heart surgery vs US were can get immediately, but have to pay for it

Major Global Health Problems: Nutrition and World Health

-provide adequate nutrition to mothers and their children -promote breast feeding -implement child feeding programs -promote healthy eating patterns

Bioterrorism: six infectious agents of highest concern.

1. Anthrax (Bacillus antracis) 2. plague (Yersinia pestis) 3. smallpox (variola major) 4. botulism (Clostridium botulinum) 5. tularemia (Frencisella tularensis) 6. Selected hemorrhagic viruses -filoviruses such as Ebola and Marburg -arenaviruses such as Lassa fever, Junin virus, and related viruses

Major Global Health Problems

1. Communicable diseases (TB, AIDS, Malaria, Diarrheal disease, MMR, Polio) 2. Maternal and Newborn's Health 3. Nutrition and World Health 4. Natural and Man-Made Disasters 5. Global Burden of Disease

WHO Disaster Fact Sheet: Communicable Diseases (know 3 points)

1. Communicable dx have potentialto cause world-wide emergencies, such as influenza pandemics 2. Natural hazard events and disasters, like droughts and earthquakes, can contribute to initial of outbreaks of endemic dxs. 3. Main causes of morbidity and mortality from communicable dxs in emergencies are: -diarrheal dx - cholera -acute respiratory infxns -measles -vector-borne dx - malaria 4. Attn to weakness in vaccine coverage is impt in disasters (esp danger infxns like measles) 5. Provision of safe drinking water and functional sanitation is crucial in management of infectious dx in disasters 6. Surveillance for rapid detection of outbreaks is essential 7. Management of dx vectors I endemic areas is req to reduce vector-borne dxs.

Role of Public Health Nursing (PHN) in Disaster Response

1. First responder -Triage and public health triage 2. Epidemiology and ongoing surveillance 3. Rapid needs assessment 4. Disaster communication 5. Sheltering -Special needs shelters

You are a nurse who is called to the scene of the mock disaster. Triage the following clients at the disaster site: A. A 60-year-old man with a broken wrist and a history of heart disease. B. A 30-year-old woman with "road burn" lacerations on her forearms and thighs. C. A 12-year-old boy with third-degree burn marks over 40% of his body.

ANS: Highest priority is always given to victims who have life-threatening injuries but who have a high probability of survival, once stabilized. Therefore, you would first attend to *C. A 12-year-old boy with third-degree burn marks over 40% of his body* because he needs severe wound care and pain management. Second priority is given to victims with injuries that have systemic complications, that are not yet life-threatening, and that could wait 45-60 minutes for treatment. So you would next see *A. A 60-year-old man with a broken wrist and a history of heart disease*. Last priority is given to those victims with local injuries without immediate complications who can wait several hours for medical attention. You would see last *B. A 30-year-old woman with "road burn" lacerations on her forearms and thighs* because her injuries are not life-threatening and can wait.

What are some organizations where nurses can volunteer to work in disasters?

ANS: The *National Disaster Medical System (NDMS)* provides nurses the opportunity to work on specialized teams such as the *Disaster Medical Assistance Team (DMAT)*. The *Medical Reserve Corps (MRC)* and the *Community Emergency Response Team (CERT)* provide opportunities for nurses to support emergency preparedness and response in their local jurisdictions. The *American Red Cross* offers training in disaster health services and disaster mental health for both response in local jurisdictions and national deployment opportunities. Other volunteer opportunities in disaster work include the Buddhist Compassion Relief, Citizens Corp, National Baptist Convention, USA, Inc, National Voluntary Organizations Active in Disaster (NVOAD), and the Salvation Army

The WHO initiative Health for All in the 21st Century can best be described as which of the following? a. Social justice initiative b. Primary care initiative c. National initiative d. Environmental initiative

ANS: A The Health for All in the 21st Century initiative is not a single, finite goal, but a strategic process that can lead to progressive improvement in the health of people. In essence, it is a call for social justice and solidarity to improve the economics and infrastructure of nations through a holistic approach to address determinants of health status and increase a community's responsibility for the health of its citizens. This may involve environmental initiatives and health promotion, education, and prevention initiatives aimed at the greater good of the population as a whole instead of serving the interests of individuals or select groups.

Disaster-related nursing is an evolving specialty. Nurses have unique skills that can be applied in which of the following aspects of disaster management? (Select all that apply.) a. Completion of the American Red Cross disaster management course and registration as a disaster responder b. Clinical management of blast lung injury c. Engagement of the BioWatch system d. Monitoring of the environment to contain infectious disease e. Planning and organization of mass prophylaxis and vaccine campaigns

ANS: A, B, D, E Nurses have skills in assessment, planning, implementation, evaluation, education, priority setting, collaboration, and provision of health care services to address both preventive and acute care needs. These skills sets are important in the four stages of disaster-related work prevention (planning/drill participation), preparedness, (course work/registration), response (clinical expertise), and recovery (monitoring). BioWatch is a system of sensors that test the air in several major metropolitan areas for biological agents that terrorists might use. This technology-based early warning system is distinctly different from BioSense, which is a public health surveillance initiative that is intended to serve as a biosurveillance program for early detection and quantification of a bioterrorism event or disease outbreak. Nursing skill sets lend themselves to participation in BioSense.

Health problems exist throughout the world. In the United States, a current health concern is the appearance of new viral strains such as Hantavirus in the Southwest. This is an example of the difference in health care concerns between countries such as: a. United States and Canada. b. Sweden and Indonesia. c. Australia and Japan. d. Bangladesh and Zaire.

ANS: B Although health problems exist throughout the world, the health care concerns of less-developed countries differ from those of developed countries. Less-developed nations such as Bangladesh, Zaire, Haiti, Guatemala, most countries in sub-Saharan Africa, and the island nation of Indonesia, have more exotic-sounding health problems like Buruli ulcer, leishmaniasis, schistosomiasis, pediculosis, typhus, yellow fever, and malaria as well as the ongoing problems of measles, mumps, rubella, and polio. Current health concerns for developed nations such as the United States, Canada, Japan, the United Kingdom, Sweden, France, and Australia are problems like hepatitis, the appearance of new viral strains such as hantavirus, and large social yet health-related issues such as terrorism, warfare, violence, and substance abuse. AIDS remains a major global concern for all countries, developed or less developed.

A nurse takes the time to read and understand the community's disaster plans and participates in mock disaster drills as a leader of the triage team. The nurse obtained disaster management training through the local Red Cross chapter and registered with the state as a disaster management nurse. The best description of the nurse's activities is: a. American Red Cross disaster training. b. community preparedness. c. personal preparedness. d. professional preparedness.

ANS: B Preparedness takes place at three levels: personal, professional, and community. The nurse who is professionally prepared is aware of and understands the disaster plans at the workplace and in the community. Preparedness also involves the development of the knowledge one needs to respond to specific types of incidents (chemical, biological, radiological, nuclear, and explosive events, and those involving weapons of mass destruction): how to treat those injured by each, how to use personal protective equipment, and how to work safely near dangerous materials. Nurses who seek greater participation or desire more in-depth understanding of disaster management can become involved with any number of community organizations that are part of the official response team. After receiving formal disaster training nurses can register with national and state registries to provide disaster response when needed. The importance of being adequately trained and properly associated with an official response organization to ensure an orderly, effective, and efficient response cannot be overstated.

An extensive train derailment occurs in the suburbs of a large metropolitan area. First responders determine that although no fatalities occurred, the derailed cars contain a noxious gas that diffuses readily into the air. The event easily overwhelms the capability of the local responders and hazmat teams are required. The local office of emergency management would coordinate through the emergency operation center to request assistance through which of the following? a. Environmental Protection Agency (EPA) b. Mutual aid agreement c. NIMS d. National Response Plan

ANS: B The first level of disaster response occurs at the locality, with mobilization of entities such as the fire department, law enforcement, public health agencies, and voluntary organizations like the Red Cross. If the disaster warrants significant local attention and overwhelms the capacity of the local responders, then the county or city office of emergency management will coordinate activities through the emergency operation center. Generally localities within a county are signatories to a regional or statewide mutual aid agreement. This agreement provides that the signatories will assist one another with needed personnel, equipment, services, and supplies. Mutual aid agreements are established between facilities and other emergency responding entities within localities, jurisdiction(s), and states; between states; and across borders to ensure seamless service in responding to disaster events, whether caused by people or by nature. When state resources and capabilities are overwhelmed, the governor may request federal assistance under a presidential declaration of disaster or emergency.

A nurse in Mexico visits a village-based health post in her region to meet with the community volunteer and health committee that operate the health post. They intended to discuss the planning for next year's health promotion initiative and evaluate the recent family planning program. This best demonstrates the aim of the Declaration of Alma-Alta to emphasize which of the following? (Select all that apply.) a. Availability of chemotherapeutic agents b. Development of maternal and child health programs c. Involvement and training of community health workers d. Organized approach to health education e. Promotion and acceptance of traditional medicine

ANS: B, C, D, E Primary health care in global health is historically based on the Declaration of Alma-Ata (1978). The WHO's and the United Nations Children's Emergency Fund still actively promote primary health care as the strategy for achieving the goal of Health for All in the 21st Century. Several major components are identified for implementation of primary health care: an organized approach to health education that involves professional health care providers and trained community representatives; aggressive attention to environmental sanitation; involvement and training of community health workers; development of maternal and child health programs that include immunization and family planning; initiation of preventive programs aimed at local endemic problems; provision of accessible and affordable services for treatment of common diseases and injuries; availability of chemotherapeutic agents; development of nutrition programs; and promotion and acceptance of traditional medicine. In this example, only three of those components are evident.

Canada is the leader in promoting a population health framework. Using such a framework, a state health department nurse with budgetary responsibility would determine that funding priorities should focus on: a. chronic disease surveillance and treatment programs. b. pediatric and adolescent primary care and nutrition programs. c. promotion of healthy lifestyles or improvement of social and physical environments. d. well and sick child clinics.

ANS: C A key to the success of a population health framework is the identification and definition of health issues and of the investment decisions within a population that are guided by evidence about what keeps people healthy. Therefore, a population health approach directs investments that have the greatest potential to influence the health of that population in a positive manner.

A major town in Zaire received a gift of retired intensive care unit monitoring equipment from a large specialty hospital in a developed country. Zaire was grateful for the donation because it would increase the technological capability to treat clients in the local hospital. However, over the next year, the monitors remained unused because personnel were not qualified to operate the monitors and no one was available to maintain or repair the equipment. This best explains the relationship between which two concepts? a. Disease prevention and health care planning b. Education and health promotion c. Global health and global development d. Primary health care and primary care

ANS: C Access to services and the removal of financial barriers alone do not account for the use of health care services. The introduction of health care technology from developed nations to less-developed nations has led to less than satisfactory results. Attention must be given to the basic needs of less-developed countries and the resources and services that the country can successfully sustain. When the focus is on the public health needs of less-developed countries, the infrastructures of the countries (economic, industrial, and technological) can be encouraged to grow in a sustainable manner.

The United States is engaged in a formal agreement with Indonesia to provide economic incentives and assistance in national defense in return for the protection of U.S. private investments in that region. Which bilateral organization is most likely involved in this agreement? a. Carnegie Foundation b. United Nations c. U.S. Agency for International Development d. U.S. Department of Defense

ANS: C Bilateral organizations or agencies operate within a single country and focus on providing direct aid to less-developed countries. All bilateral organizations are influenced by political and historical agendas that determine which countries receive aid. Incentives for engaging in formal arrangements may include economic enhancements for the benefit of both countries, national defense for one or both countries, or enhancement and protection of private investments made by individuals in these nations. The U.S. Agency for International Development is the largest of these and operates totally outside of the United States.

A terrorist bombing at a local church has sent many victims to the local emergency department and resulted in several deaths. Following the event, an emergency department nurse seeks out other nurses who are having difficulty performing their jobs to speak about the event. The nurse is demonstrating the disaster response strategy of: a. allaying public concern and fear. b. assisting victims to think positively and to move to the future. c. identifying feelings that individuals may be experiencing. d. preparing personnel to be effective in a disaster.

ANS: C During the aftermath of a disaster or terrorism event, nurses can feel fear, hopelessness, and loss or bias, hatred, vengeance, and violence toward ethnic or religious groups that may be associated with terrorism. These feeling may compromise their ability to provide care for these groups. Yet the International Council of Nurses' (ICN) Code of Ethics for Nurses (2000) affirms that nurses are ethically bound to provide care to all people. One strategy to use in response to a disaster or terrorism event is to assist in identifying the feelings that nurses or others may be feeling. To accomplish this, the nurse can (1) explain that feelings of fear, helplessness, and loss are a normal reaction to a disruptive situation; (2) work with people and help them think of what they did that helped them overcome fear and helplessness in previous situations; (3) encourage people to talk to others about their fears; (4) encourage others to ask for help and provide resources and referrals; (5) remember that those in the helping professions may find it difficult to seek help; and (6) convene small groups in workplaces with counselors/mental health experts.

In developed countries, nurses have an important leadership role in primary health care initiatives. Commitment to which of the following best demonstrates nursing's advocacy role in primary health care? a. Equality of health care b. Higher education for nurses c. Provision of direct client care d. Quality of care

ANS: C In developed countries, nurses are often viewed as one of the strongest advocates of primary health care through nursing's social commitment to health care equality.

A nurse is working with a disaster medical assistance team as it responds to a disaster. A new team member excitedly insists that its personnel can exceed their 12-hour shifts and do not need breaks. The best intervention on the part of the nurse is to: a. arrange for the team member to be transferred to another unit. b. arrange for the team member to leave duty, return home, and talk with his or her pastor. c. educate the rescuer about necessary stress-management techniques and offer to pair up with the individual so that each can monitor the other's stress level. d. help the team member to call home to speak with his or her family.

ANS: C The nurse needs to be aware that rescue workers are repeatedly exposed to stress and, despite their training in managing such situations, have a higher than normal risk of developing post-traumatic stress syndromes. The nurse can assist the new team member by educating the rescuer about the importance of stress-management and self-management techniques. The nurse could pair up with the new team member so that they could monitor each other's stress responses and could provide guidance in adhering to stress management techniques.

A nurse wishes to become actively involved in disaster management and is extremely interested in providing first aid and delivering aggregate health promotion, disease prevention, and emotional support. It would be ideal for the nurse to train and volunteer as which of the following? a. Community emergency response team member b. Disaster medical assistance team member c. Member of the Medical Reserve Corps d. Red Cross shelter manager

ANS: D Creation and operation of shelters are generally the responsibility of the local Red Cross chapter, although the military may be charged with setting up "tent cities" or mobile home parks for large groups of people needing temporary shelter. Because nurses are comfortable performing tasks such as aggregate health promotion, disease prevention, and provision of emotional support, they make ideal shelter managers and team members. The Red Cross provides training in shelter support and use of appropriate protocols.

After a mock disaster drill, the nurse participates in a "hot wash" of the exercise in which participants from all units speak about successes, problem solving, failures, and unanticipated challenges or obstacles faced during the mock disaster drill. This activity best addresses the public health workforce competency of: a. describing the agency chain of command. b. identifying the limits of one's own knowledge, skill, and authority. c. recognizing unusual events that might indicate an emergency. d. writing after-action reports, updating implementation plans, and implementing changes.

ANS: D Federal agencies and professional organizations have outlined competencies for public health professionals at all points of the disaster management cycle. One competency speaks to the ability to evaluate drills, exercises, or actual events. As valuable components of preparedness, mass casualty drills and exercises can help rescuers develop the necessary coordination, skills, and confidence to operate effectively and efficiently across disciplines and agencies. Special emphasis is placed on the after-action reporting once the exercise is over, which ultimately allows improvement of the overall all-hazards disaster response plan. Such sessions may be referred to as debriefings, hot washes, or postings. Participation in these sessions develops the critical skill of evaluation that allows for process improvement.

A nurse is assigned to provide community outreach to a small town that was partially destroyed by a tornado 3 years earlier and has been rebuilt. The first client is a family who lost their home and their best friend in the tornado. The best intervention would include: a. assessment of the family's home environment to rule out safety issues. b. avoidance of discussion of the disaster of 3 years ago. c. consideration that the family will have worked through the emotional aftermath by now. d. support of the family in preparing a personal disaster response plan.

ANS: D The approach of relief activities needs to shift from short-term aid to long-term support. Promoting individual, family, and community preparedness increases safety in the event of disaster and can help children and adults feel empowered. This builds on the resilience of the individual, family, and/or community. Individuals and families still need to be assessed for indications of mental distress (case finding) and referred to a mental health professional if the need exists. Open discussions of the family's response to the slow process of recovery or long-term results of living under adverse conditions can uncover lingering mental distress or exacerbations of chronic conditions that require attention. During the initial stages of recovery environmental safety issues should have been addressed.

The North American Free Trade Agreement, passed in 1994, allowed increased importation of goods and eased the movement of people throughout the United States, Canada, and Mexico. A health impact of this agreement for southern Texas has included: a. decrease in illegal immigration into the United States as a result of the improved Mexican economy. b. decrease in tuberculosis, cholera, and tetanus as a result of economic development. c. improved nutrition as a result of plentiful fresh vegetables and fruits in local markets. d. increase in respiratory and diarrheal disease as a result of colonias settlements.

ANS: D The colonias (colonies) are settlements of workers along borders in California, Arizona, New Mexico, and Texas. More than 40,000 Texans live in colonias along the southern Texas border. Environmental conditions in the colonias, such as lack of roads, transportation, water or electrical services, and access to primary care, have resulted in increased preventable infectious diseases (amebiasis, respiratory, and diarrheal diseases), environmental health hazards, and injuries associated with determinants of poverty, poor sanitation, and overcrowded conditions.

The major factor that has led to sharply increased insurance payouts following disasters in the United States in recent decades has been: a. El Niño. b. geography. c. technology. d. human development.

ANS: D The cost in more developed countries is higher because of the extent of material possessions and complex infrastructures, including technology. In the United States, increases in population and development in areas vulnerable to natural disasters, especially coastal areas, have led to sharply increased insurance payouts.

The emergency support functions of the National Response Framework (NRF) and the National Incident Management System (NIMS) provide: a. authority to step in and take control of state, local, and voluntary organizations during disasters. b. command and control for American Red Cross and Disaster Medical Assistance teams. c. oversight of federal and state response operations, with minimal interaction with other organizations. d. written approach, protocol, and common language for responders from federal agencies and other voluntary organizations.

ANS: D The first level of disaster response is carried out by the locality (office of emergency management). Through mutual aid agreements, localities can arrange for additional support from surrounding communities (emergency operations center). When the response needs exceed the capability of the localities and state-level resources or capabilities, then the governor may request assistance under a presidential declaration of disaster or emergency. The way the federal government offers assistance is through the NRF. The NRF was written to approach a domestic incident in a unified, well-coordinated manner that enables all responding entities to work together more effectively and efficiently. All member organizations of the responding teams, including all relevant branches of the federal government, are assigned functions that are listed in the plan as emergency support functions. When large disasters require the services of a variety of emergency responding units with personnel coming from different parts of the country, the challenge of working together in unison may require the use of the NIMS, which provides all responders with a protocol and common language for working together. The importance of interoperable communication equipment is stressed by the NIMS.

The highest priority for a nurse who is among the first responders to a disaster is: a. arranging for shelter for disaster providers. b. beginning community assessment as soon as possible to ensure a rapid recovery. c. beginning surveillance and planning needed health education for disaster survivors. d. immediately developing plans for effective triage and client management.

ANS: D The first priority when responding to a disaster is to immediately plan for, coordinate, and carry out effective triage. Disaster response includes community assessment, surveillance, health education, and coordination of shelter arrangements. However, the first task is to provide care for life-threatening injuries and conditions.

Mortality rates do not accurately describe the health status of populations in the world. The World Health Organization (WHO), in 2009, and World Bank, in 2005, developed an indicator—the global burden of disease—that combines losses from premature death with losses of healthy life that result from disability. The indicator represents: a. costs to the world of treating communicable disease in less-developed countries. b. economic cost of preventable early deaths. c. impact of disability on the international economic forecast. d. years in lost contribution to economic growth.

ANS: D The global burden of disease indicator utilizes the unit of disability-adjusted life-year (DALY). This unit measures the combined time lived with a disability and time lost as a consequence of premature death. The time lost because of premature mortality is calculated using standard expected years of life based on gender, whereas the reduction in physical capacity as a result of morbidity (disability) is measured using a six-point scale from 0 (perfect health) to 1 (death) that reflects the degree of dependence of the young and older adults on the adults in the population. The DALY represents life-years lost that could have contributed to the economic growth of a family or country as a consequence of premature death, disability, or loss of caregiver potential productivity/contribution.

Bioterrorism agents & Nursing Role; Community Preparedness: 10 FEMA regions

Anthrax Plague Smallpox (vaccination) Botulism Viral hemorrhagic fevers Tularemia Nursing Role: -*Recognition*: be alert to patterns of clustering of illnesses -*Protective measures*: follow facility's procedure (*special isolation or decontamination*) -*Interventions*- antimicrobial therapy

Disaster Management and Care: defining disasters

Any natural or human-made incident that causes disruption, destruction, and/or devastation requiring external assistance The disaster event type and timing predict subsequent injuries and illnesses.

Nurse's Role

Coordinate efforts to ensure optimal safety and health of the community Establish a command center for debriefing and task assignments Ensure community members and health care providers are aware of available resources

UN Millennium Development Goals (MDGs) (2005)

Dev to relieve poor health conditions around the world and to establish positive steps to improve living conditions by year 2015 Goal 1: Eradicate extreme poverty and hunger Goal 2: Achieve universal primary education Goal 3: Promote gender equality and empower women Goal 4: Reduce child mortality Goal 5: Improve maternal health Goal 6: HIV/AIDS, malaria and other diseases (TB) Goal 7: Ensure environmental sustainability Goal 8: Develop a global partnership for development

Healthy People 2020: Disasters

Disaster incidents have an effect on almost every objective. Disasters play a direct role in the objectives related to *environmental health, food safety, immunization and infectious disease, and mental health and mental disorders*

Disaster Management Cycle: Stage III: Response

First level of disaster response occurs at the *local level* with the mobilization of responders, such as the fire department, law enforcement, public health, and emergency services -Then State, then National Response to *bioterrorism*: -BioWatch: early warning system for biothreats that uses an envir sensor system to test air for biological agents in several major metropolitan areas; https://www.cfda.gov/?s=program&mode=form&tab=step1&id=70efc816418408a181647668d1b045bb -BioSense: data-sharing program to facilitate surveillance of unusual patterns of clusters of dx in the U.S.; Shares data with local and state health depts and is part of BioWatch system; http://www.cdc.gov/biosense/

Required Nursing Skills for Disasters

Flexibility, Creativity Leadership, Delegation Coordination Ability to Educate Not "High Tech" Nurses have unique skills for all aspects of disaster: assessment, priority setting, collaboration, and addressing both presentative and acute care needs PH Nurse skills: heath edu and dx screening, mass clinic expertise, ability to provide essential public health services, comm resource referral and liaison work, population advocacy, psychological first aid, public health triage, and rapid needs assessment.

Hurricane Katrina

Hurricane Katrina was the largest and 3rd strongest hurricane ever recorded to make landfall in the US. In New Orleans, the levees were designed for Category 3, but Katrina peaked at a Category 5 hurricane, with winds up to 175 mph. The final death toll was at 1,836, primarily from Louisiana (1,577) and Mississippi (238). More than half of these victims were senior citizens. The storm surge from Katrina was 20-ft (six meters) high. 705 people are reported as still missing as a result of Hurricane Katrina.

Determinants: factors and conditions that are important considerations in population health

Income and social factors Social support networks Education Employment Working and living conditions Physical environments Social environments Biology and genetic endowment Personal health practices Coping skills Health services Sex Culture

Partners: Resources and Agencies

Local Public Health Department American Red Cross Center for Disease Control Federal Emergency Management Agency(FEMA) Wisconsin Electric Fire and Police Departments Medical Equipment Agencies Local Volunteers

Major Global Health Organizations: 3 major divisions

MULTILATERAL 1. *World Health Organization (WHO)*: autonomous org that works with UN through its Economic and Social Council 2. *United Nations Children's Fund (UNICEF)*: a subsidiary agency to UN Economic and Social Counsel; advocate for women and children under age of 5; safe drinking water, sanitation, edu, maternal and child health 3. *Pan American Health Organization (PAHO)*: multilateral agency focused effort to improve health and living stands of Latin American countries 4. *World Bank*: multilateral agency r/t UN; lend $ to lesser dev countries to improve health status of ppl 5. *Catholic Relief Services (CRS)*: official international humanitarian agency of Catholic community in the U.S; alleviates suffering and provides assistant to those in need who are affected by war, starvation, famine, drought, and natural disasters in more than 100 countries w/o regard to race, religion, or nationality BILATERAL & NGO or PRIVATE VOLUNTARY -Non-governmental Organizations (International Red Cross, Medicins San Frontieres) -Religious Organizations (Maryknoll Missionaries, CARE, and Third World First) 6. *International Red Cross* (NGO): lays groundwork for health intervention as a results of a country's emergency; disaster relief and emergency aid; volunteer organization PHILANTHROPIC -Philanthropic Organizations (W. K. Kellogg Foundation, Milbank Memorial Fund, and Pathfinder Fund) Peace Corps

Disaster Care Summary

Nurses must continue to plan/train in an all-hazards environment, regardless of specialty practice. PHNs are especially critical in the multidisciplinary disaster health team, due to population-based focus & specialty knowledge in epidemiology, community assessment. Staying current requires the PHN's commitment in community planning activities, exercise participation, and actual disaster work.

Nursing and Global Health

Nurses play a leadership role in health care throughout the world Nurses with public health experience provide knowledge and skills in countries where nursing is not an organized profession - give guidance Developed countries - Provide direct care, education, health promotion, advocates Less developed countries - nursing poorly defined; care dependent on physicians

Levels of Prevention: Global Health Care

PRIMARY -Teach ppl how to avoid or change risky behaviors that might lead to contracting HIV SECONDARY -Initiate screening programs for HIV TERTIARY -Manage sx of HIV, provide psychosocial support, and teach clients and SO's about care and other forms of sx management

Disaster Management Cycle: Stage II: Preparedness

Personal -Disaster kits for home, workplace, and car Professional -National Disaster Medical System (NDMS): Disaster Medical Assistance Team (DMAT) -Medical Reserve Corps (MRC) -Community Emergency Response Team (CERT) Community- disaster plans National Health Security Strategy (NHSS): Disaster and mass casualty exercises

Primary Health Care (PHC)

Promoted by WHO and UNICEF who maintain that the training of health workers needs to be based on current primary health care practices Advocate for community members to be involved in all aspects of the planning and implementation of health services that are delivered to their respective communities Example: Mexico - nursing not valued and ability of nurses to contribute is minimal; cultural and gender-role barriers; in other lesser-dev countries too like Africa and the DR Ultimate goal: achieve better health for all 5 key elements to achieve goal 1. Reducing exclusion and social disparities of health 2. Organizing health services around ppl's needs and expectation 3. Integrating health into all sectors 4. Pursuing collaborative models of policy dialogue 5. Increasing stakeholder participation

Nursing Interventions

Provide breaks, sleep, food in small amounts, fluids Use humor, positive talk Listen, provide support, time to debrief

Factors that Increase Risk for PTSD

Proximity to the event (dose-response phenomenon) Multiple stressors History of trauma Meaning of the event in relation to past stressors History of chronic medical illness or psychological disorders

Major Global Health Problems: Maternal and NB Health

Reduce infant mortality -provide skilled birth attendants -develop adequate facility support -promote prenatal care -prevent mother to child transmission

Recovery: The Third Component of the Disaster Management Cycle

Role of the nurse is multifaceted -Flexibility -Teaching health promotion and disease prevention -Case finding and referral

Healthy People 2020: Global Health Care

Selected objectives that apply to Global Health Care: - EH-1: Increase the proportion of persons served by community water systems who receive a supply of drinking water that meets the regulations of the Safe Drinking Water Act - EH-5: Reduce waterborne disease outbreaks arising from water intended for drinking among persons served by community water systems - FP-1: Increase the proportion of pregnancies that are intended - GH-1: Reduce the number of cases of malaria reported in the US - HIV-1Reduce the number of new HIV diagnoses among adolescents and adults - MICH-3: Reduce the rate of child deaths

Examples of Nurse Leadership Roles Globally

South Asia Tsunami Earthquakes in Chile and Haiti (2010) Children's hospital in Uganda Quality improvement program in the Congo Emergency service program in Mongolia Community-based TB program in Switzerland China and Taiwan

Review of Disaster Management Cycle

Stage I: *Prevention* (mitigation & protection) -Assess for Vulnerability, special needs populations -Educate about the Effects of an Event -Evaluate Understanding of preparation Stage II: *Preparedness* -Assure Capacity to Respond to a Disaster -Conduct Training, Drills and Exercises to Evaluate preparedness Stage III: *Response* -Provide Support -Determine Impact and Specific Health Needs -Triage Victims Stage IV: *Recovery* -Restore Systems to Functional Level -Assess Assets and Potential for Recovery -Partner with Community Leaders

Major Global Health Problems: Communicable Diseases

Tuberculosis: 95% in low to mid SES countries; worldwide one of top 3 causes of death; *trend worldwide: declining. Two things threatening tis: HIV and growing antibiotic resistance* HIV/AIDS: *ppl living longer with HIV*, more of chronic dx as opposed to death sentence, b/c of mediations, more knowledge about dx, improved screening (early detection); *new HIV infection declined since 2000s* b/c decrease in transmission due to education and safe sex practices; 52% cases are women Malaria: *decreased 45%* globally since 2000; *decreased 49%* in sub-Saharan Africa since 2000. Diarrhea diseases: unsafe drinking water, poor hygiene; staying same overall, but more prevalent in 3rd world countries *Those who suffer from HIV are much more likely to suffer/die from TB - correlation*