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NUR 422: Community Health Nursing Midterm

Terms in this set (408)

What is community/public health nursing?

Looking at the roles of public health nursing
Caregivers - providing care to patients such as home care
Educator - able to educate more on one to one basis and may see clients for a longer period of time
Advocacy - supporting the patient
Manager - managing the patient's care
Community health nursing is the synthesis of nursing and public health practice applied to promote and protect the health of population. It combines all the basic elements of professional, clinical nursing with public health and community practice.
Community health nursing is essential particularly at this point
in time because it maximizes the health status of individuals,
families, groups and the community through direct approach with them. ( Mengistu, D & Misganaw, E, 2006)
This occurs at the individual, community and population level

What is the community health nursing process?

Establishing and monitoring a working relationship
Assessing the health and nursing situation
Establish the goal for health and nursing care
Construct and implement a program of action
Evaluating the action
How to evaluate our outcomes?
Have to have a baseline of what is the problem such as how many children that are not immunized
Such as Goal is to immunized 30% of the population that are not immunized
Scope or standard of practice - that dictate how we should practice, how do we provide quality level of practice and each discipline has their own scope and standards of practice and some of things that community nurses do is stablish a working relationship so working with people and developing a trusting relationship.

What is the concept of health?

Health - The state of complete physical, mental and social wellbeing and not just the absence of disease. (WHO)
The concept of health is wide and the way we define health also depends on individual perception, religious beliefs. Cultural values, norms and social class.
Nurses and the work environment - stressful, other healthcare providers, wearing the appropriate PPE
Increase incidences with children with birth defects
Increase incidences of asthma
Work with a cleaning products and what are the implications of using that cleaning products

What is social determinants of health?

Your zip code is more important in determining how long you will live your life than your genetics. Even with your behavior because of the environment which you live in is an indicator of what kind of healthcare you receive, what kind of healthy foods you are able to eat
So zip code is a determinant of what is your long term health
For example, Kensington Neighborhood in Philadelphia
Badland, poorest of the poor
People have access to food such as little corner places and not healthy food
Healthy food is expensive and not as accessible
You can feed an entire family for 8 dollar on McDonalds
Increase risk of CVD, childhood obesity and DM
In Manhattan, there was a program in which they developed a food prescription program where family would come into the clinic and the doctors were giving them prescriptions for healthy fruit and vegetables that families could use to go to the food markets and use the voucher to get fruits and vegetables

What is primary health care?

Primary Health Care: "Essential health care based on practical scientifically sound, and acceptable methods and technology, made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every state of their development in the spirit of self reliance-and self determination. (WHO)
Based on the primary, secondary and tertiary healthcare
https://www.youtube.com/watch?v=Lk3qnb6gekU (10 min)

How the other half lives

https://www.youtube.com/watch?v=EACoIbokOcc
Jacob Riis wrote a book on how immigrants live in cities such as NYC
10 minutes video

Nursing Care in the Community

It is very important to have full knowledge of community/population/public health care no matter the setting you choose to work in after graduation.
Focus on health
State of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity

Community nursing definitions

Community-Oriented Nursing Practice is a philosophy of nursing service delivery that involves the generalist or specialist public health and community health nurse providing "health care" through community diagnosis and investigation of major health and environmental problems, health surveillance, and monitoring and evaluation of community and population health status for the purposes of preventing disease and disability and promoting, protecting, and maintaining "health" in order to create conditions in which people can be healthy.
Public Health Nursing Practice is the synthesis of nursing theory and public health theory applied to promoting and preserving health of populations. The focus of practice is the community as a whole and the effect of the community's health status (resources) on the health of individuals, families, and groups. Care is provided within the context of preventing disease and disability and promoting and protecting the health of the community as a whole. Public Health Nursing is population focused, which means that the population is the center of interest for the public health nurse. Community Health Nurse is a term that is used interchangeably with Public Health Nurse.
Community-Based Nursing Practice is a setting-specific practice whereby care is provided for "sick" individuals and families where they live, work, and go to school. The emphasis of practice is acute and chronic care and the provision of comprehensive, coordinated, and continuous services. Nurses who deliver community-based care are generalists or specialists in maternal-infant, pediatric, adult, or psychiatric-mental health nursing.

Community and Population

Community
Group of people who share something in common
Interact together
May show a commitment with one another
May share geographical boundary
i.e. Night Shift Nurses in the CCC at Jefferson
Population
Group of people who have at least one thing in common but may or may not have interaction.
i.e. All night shift nurses

Population vs public health care

Population Focused Care
Focuses on health promotion, disease prevention that shapes the community's overall health status
Public Health Nursing
Population focused with knowledge of nursing, social, public health sciences
Goal is to promote health and prevent disease/disability for all people by creating conditions which people can be healthy
Communities priorities and needs
May have a relationship within the community (or not)
Grounded in social justice, compassion, sensitivity and respect for all populations especially those who are vulnerable
Medicare is the driver of good standard of care
Such as the hospital doesn't get paid if someone has a readmission rate within 30 days of the discharge

Public health vs Medical care

Individual vs. Population
Healing vs. Prevention
Diagnoses vs. Assessment
Treatment plan vs. Policy Development (EBM)
Treatment vs. Assurance
Achievements in public health care more difficult to recognize. Often taken for granted.
Such as when I turn on the tap water, Im going to have clean water - may not be the case in other countries

Essential public health services

Core Functions
Assessment:
Identify community health problems and identify and diagnose problems and hazards to the community
Policy Development :
Inform, educate and empower people about health
Partnerships to identify and solve problems
Develop plans and policies that support the community
Assurance:
Enforce the laws and regulations that protect
Link people to services not available
Ensure competent system of workers
Evaluate the efficacy of the system. (Schneider, 2011)

Top 10 public health achievements in the 20th century

Vaccination
Motor-vehicle safety
Safer workplaces
Control of infectious diseases
Framingham study
Decline in deaths from coronary heart disease and stroke
Safer and healthier foods
Healthier mothers and babies
Family planning
Should talk more of dental health
Young people with poor teeth a question mark should go off in your mind like are you using drugs? Meth mouths
Fluoridation of drinking water
Recognition of tobacco use as a health hazard

What community nurses do?

Risk Assessment and risk management
Home Care/Hospice
School nursing
Health center nursing
Public Health nursing
Community Educators
Mobile Nursing
Industrial health nursing
Why is the Care Different?

Differences between acute and community care

Acute Care
Predictable Routine
Policy and Procedure
Immediate consolation and collaboration
Standardization of Care
Controlled patient compliance with the plan
Community Care
The nurse is dependent on the patient wiliness to share information
Need to assess environmental conditions and role its play in achieving health.
Routine not as pre-determined
Diverse resources
Autonomy

Our world vs their world

In our world
Meds are given on time and if they are not there ...we get them
If PT is ordered the PT is received.
If the wound care is to be done three times a day, it gets done three times a day
The patient eats when we say eat, the patient bathes when we say bathe...
Pain medications are given in an appropriate manner and the response is monitored
In their world
The meds are taken when the individual decides to take them
If they decided if was too cold to go out to CVS to pick up their meds, or they ran out of refills so the mail order did not send them out this quarter, They do not have them and subsequently do not take them
If their granddaughter had a school show the same time as PT, then often it is decided not to go to PT
If one pain pill doesn't work or if it wears off in 2 hours they can take another one and take it with a glass of wine or shot of whiskey.
If the individual's neighbor helps with wound care and she went to the shore for the weekend.... The dressing may not be changed.
Look at the perspective of the patients allowing me to provide care for them, it gives the patient rights. Rather than Im coming in and Im going to give your care today
This is why community care is so much fun and quite the challenge!
It is no longer "this is what is ordered so take it "
Need to use all your assessment skills and knowledge to provide care but also have to take into consideration everything that is happening to the patient.
Every encounter is different
Education
Socioeconomics
Health Literacy
Support System
Religion/Political Views
Culture regarding health, pain, time etc.....

Kings Theory of Goal Attainment

Goal of nurse: "To help individuals to maintain their health so they can function in their roles."
If the problem can be identified then actions can take place to fix them
If nurse and patient have mutual goals then satisfaction can occur
If there is conflict, the relationship cannot thrive
When goals are achieved, growth in the relationship can occur
Ask the patient what is the most important thing I can do for you today. What is the most important to you today that I can provide for you? - very different perspective

Cultural Assessment

Diversity and Culture

Sooooooo much more than acknowledging differences or not saying something offensive
Culture of society-family, SO, town, region, nation
Things to be aware of before "touching the patient"
Space, Belief in destiny, religion, respect
What is your value system?
Important to know practices among different cultures
Bruising in cup shaped - cupping which is a popular practice not being abused!
We have to be aware of certain behaviors and how do we institute change slowly

Stop and think

What are things which were totally not mainstream or even considered socially unacceptable in 1988 which are common place and "normal" in 2016.
What would be something that if I came into your neighborhood that would be so "not good" if I did it.
What would might be a health disparity in your community that public health interventions might be needed. CBPR

Quarantine vs isolation

Communicable diseases began to overrun Europe during the Middle Ages such as bubonic plague. It is believed 60 million deaths occurred. Began the practice of quarantine
Quarantine is used to separate and restrict the movement of persons; it is a 'state of enforced isolation'.[This is often used in connection to disease and illness, such as those who may possibly have been exposed to a communicable disease. (CDC)
Isolation "to separate ill persons who have a communicable disease from those who are healthy." (CDC)

History

First Home Visits provided by Sisters of Charity founded by St. Vincent De Paul in 1633
First organized visiting nurses association
Believed that hospitals were disruptive and people would heal better in home (Has this changed?)
Nursing went though a dark time where the profession was not seen as admirable and only illiterate, lay workers were only one to do the job. Punishments for prostitutes
Yellow Fever Outbreak in Philadelphia 1793
Began in Summer, 1793 when people were falling to a disease which caused flu like illness in which people recovered and then became sick again "turning yellow and having black vomit"
Benjamin Rush, a physician and signer of Declaration of Independence believed it was due to rotting coffee beans on the docks on Delaware Ave.
" I found that all the deaths had taken place a short distance of the (broad street) pump.... I had an interview with the Board of Guardians of St. James parish....In consequence of what I said, the handle of the pump was removed on the following day." (John Snow)

Yellow Fever

Over 5000 people died including 1000 in the month of October. Many people fled including the president, the cabinet. Mostly rich
Common for people to empty their chamber pots in the Delaware or if not willing, simply in the streets.
The summer was hot and dry and the mosquitos were plentiful
Ship of refugees from the Caribbean had landed in Philadelphia bringing many new people to the city.

Medical improvements

Jenner developed the first small pox vaccine in 1789
Louis Pasteur -we think milk but actually started with wine! Pasteurization
Koch: Father of microbiology and discovered anthrax
Klebs in late 1800's discovered the germ theory. One of the greatest achievement in 19th century http://ocp.hul.harvard.edu/contagion/vaccination.html

Poor Benjamin Rush

It was not until the early 1900's the chain of causation was established for the outbreak.
The refugees had brought the Yellow Fever to Philadelphia and the many mosquitos drawn by the raw sewage spread the disease through the bite.

Chain of causation

What is germ Theory?

The germ theory of disease states that some diseases are caused by microorganisms. These small organisms, too small to see without magnification, invade humans, animals, and other living hosts. Their growth and reproduction within their hosts can cause a disease.

Advance

Chadwick Report (1837)
Studied conditions of the laborers in Great Britain
More than half the children died by age 5 and adults lived half as long
Living conditions were considered major cause
First board of health was established and social reform was initiated
Shattuck Report (1850)
Report of the Massachusetts Sanitary Commission
Recommendations for public health
Need to keep statistics
Monitoring system to provide information to the public about food, infection control
Was ignored early on and the recommendations took almost 20 years to implement
Precursor to health insurance

Industrial Revolution

Changes in technology changed everything
People moved to the cities and overcrowding , sanitation issues were a problem
Child labor, industrial health issues

Epidemics of disease

John Snow and Cholera Epidemic
Father of epidemiology
Cholera epidemic in 1854
Snow did not accept that miasma (bad air)theory of cholera transmission. Believed instead it was transmitted by water.
Able to identify a specific pump in broad street as the source of the disease.
Had handle of pump removed and disease immediately began to diminish

Florence Nightingale - History

Known as the founder of modern professional nursing
First school of nursing at St. Thomas Hospital in London in 1860.
She worked on conditions to improve care to the acutely ill but focus on wellness in the community
Manipulating the environment to allow healing to take place
Struggle with disparity in world as she was wealthy
Parents would not let her be a nurse, studied sciences and collected data about public health
Finally went in 1851 at age 31
Wrote papers on feminism "Cassandra"
Crimean War started and she was asked to set up hospitals for the soldiers. Took 38 nurses.
Horrible conditions but they fixed it
She never bought into the germ theory but she believed in environment and sanitation
Mortality was decreased from as high as 73% to 2% in 6 months Illustrated London News 2/24/1855
People did not like her.
Received grief and disrespect from the army officials and the physicians
Until she was able to get the press involved.
Lady with the lamp
Help to established the professional nursing and the standards in which nurses would practice

Nightingale - Meaning to Nursing

Changed the face of nursing forever
Insisted nurses be educated
"Nightingale nurse"
Focused on autonomy
Initiated licensure so as not to lose control of the education process
Community Nursing
Health nurse needs to focus on the poor
Good teachers
Needed additional training before being a district nurse
Preached prevention

Mary Secole

First black nurse in america
Worked with Florence Nightingale
Worked against all discrimination
Originally from Jamaica, she was educated in Creole medicine
Nightingale did not want her services and she started a home for the invalid. Eventually went bankrupt but known as a major contributor in development war time nursing

Lillian Wald

A wealthy woman of German-Jewish descent attended nursing school in New York
In 1893 began home class for immigrant families in the lower east side of Manhattan
One of the children came to her in broken English and explained "mommy-blood-baby" and when she arrived realized mother having post partum complications that physician left because there was not money
Recognized nursing could provide for these people and with Mary Brewster they developed the Henry Street Settlement
Founder of Public Health Nursing
Developed what would become the Visiting Nurse Service of NYC
Started first school nursing role
Care focused on resolving disparities of health care through the social determinants
10 nurses in 1893—250 nurses in 1916
Established school nursing which focused on why children were absent or dismissed from school. Initially was a volunteer position from Henry Street after one year there were 12 nurses hired
In 1909, she began a relationship with Met Life to provide nursing visits to their policy holders .
Statistics showed lower mortality rates. Lasted until 1953.
Started the Henry Street Settlement - still existed today
Video on Henry street
https://www.youtube.com/watch?v=CZu1LHdoMUY

https://www.youtube.com/watch?v=lCPMcxNVdPU
Single family households with children is the largest population of poor in USA
Poverty level is $11,000 a year, $23,000 for a family of four They don't receive all of the services and the goal for HSS is that they get out of that situation and they can move on and they are given tools to do that

Mary Breckinridge - Different from Mary Brewster

Was born into an "influential" family in 1881. Her husband died only after 2 years when she was 26. She went to NY and became a nurse. She remarried and had 2 children but both died at very early ages. Her husband was --- And they divorced.
Went to Europe during WWI and saw the role the midwives played and realized this could help the problems in her rural eastern Kentucky area
She went to London became a CNM and in 1925, she started the Frontier Nursing Service
She was able to raise $6 million dollars and
Established a model of rural care in the US and the world which exists today.
They travel on horse and foot to provide care in homes.
Rates of death markedly reduced.One of her nurses started first midwife program in NY and she started one in KY
Also started what would become the ACNM

WWI

Vassar Training Camp: decreased training form 3 years to 2 years. Went into Army Reserve.
After WWI the number of public health nurses decreased because of the training of the hospital nurses for the war.
1917: 45 states have enacted nurse practice acts and use term RN
1918: Pandemic influenza outbreak. Had to turn every available building into a "hospital". Nurses were dying.
Mary Sewall Gardner wrote first textbook on public health nursing
1919: Public health nurses were staffing Ellis Island
Sheppard Towner Act 1921
Federal money to develop health clinics for Maternal/Child health.
Over 80% of woman were not receiving prenatal care
Second leading death of women was child birth
Found large majority of young soldiers were rejected because of sequelae of childhood diseases

The depression in the 1930's the New deal provided for the underserved

More Federal government role in public health
Wanted a public health nurse in every county
National Organization of Public Health Nursing instrumental during this time
Development of Crippled Children Services
Public health involvement of syphilis . Notification of disease, partners , follow up treatments
Increase in the role of the industrial health nurse

World War II and Forward

School nurse guidelines established
War changed the role as more nurses were educated through the Nurse Cadet Corps. Education was shortened and focus on acute care abroad so there was a section on public health and polio care
Still nursing shortage
Penicillin
It was the army that was the first group to upgrade the education level that is needed for nurses

After the war, numbers of communities surged

Roles increased in rural areas and nursing homes
Providing vaccine and TB screening
Nursing education changed with addition of community colleges
Polio vaccine 1955

1960's to 1970's

Community based psychiatric care
Development of Advanced practice roles in primary care. First NP in rural Colorado in 1965
Sexual revolution increased STI and teen pregnancy
1965:Medicaid and Medicare established
The introduction of the DRG (diagnosis related groups) made major impact in health care late 70's -early 80's
CHANGED EVERYTHING
Insurance reimbursement for home care

Whole new world 80 - 90's

1987: States could increase their Medicaid and focus on public health at the state level.
Focus turning to chronic disease
High risk mothers and infants
Case Management: Friend or Foe???
HIV/AIDS
Increasing TB- monitoring programs
Resurgence of vaccine prevented diseases
Advanced Practice Nurse Reimbursement for Medicare at 85%

1990's

Dark times in health care
IOM report in 1988: highlighted worries of public health care system
Threats of health care reform...
Hillary Clinton
HMO
Despite the fact no program there was reform
1993: AZT
Life expectancy rose from 43 yrs. to 73 yrs. in 1990
Increase in Hep B, Hep C and Syphilis due to drug use
Wanted 90% of children immunized by age 2
Ambulatory Care Centers
Same day- 23.9 admissions now
Focus is on chronic diseases like Diabetes and not communicable disease like Polio

9/11 changed everything - more federal involvement

Bioterrorism
Small pox vaccine
Changes in nursing education
Managed care
New IOM report Assuring the Health of Public in the 21st Century (2008)
Increasing assurance
Social determinants
Increase nursing role in population care
Ecological model
Public Policy
Medicare and Medicaid - set the gold standard of what insurance is
It is what drive healthcare
Federal government provides what are called block grants that are provided to the states and they can disperse the monies by these block

Social Determinants of health

Genetics - 20%
Natural environment - 20 %
Health Behaviors - 50%
Medical Care - 10%
Commission on Social determinants of health
http://www.who.int/social_determinants/en/
The social determinants of health (SDH) are the conditions in which people are born, grow, work, live and age and the wider set of forces and systems shaping the condition of daily life. These forces and systems include economic policies and systems, developmental agendas, social norms, social policies and political systems.
Youtube video of social determinant - by ccmu

Changed process target for change and strategies for change

Individual
Family, Social Networks
Organizations
Community - might be everyone knows each other and could be like a neighborhood
Population - looking at a segment of people that have similar health issues
Place Matters
http://www.commissiononhealth.org/Education.aspx
Neighborhoods and poverty in Philadelphia

Gaps in health across neighborhoods stem from multiple factors:

Education and income
Unsafe or unhealthy housing
Opportunities for residence to exercise, walk, or cycle may be limited.
Proximity to highways and factories
Access to primary care
Unreliable or expensive public transit
Residential segregation

The ACA (affordable care act)

Payment for Prevention Care
Increases Medicaid Access to the states through blocked grant
Family Planning
Improves access by
Donut Hole in Medicare Part D
Part A,B,C and D
D - focuses on prescription not totally clear

Ethical issues in nursing

Informed Consent
Individual Freedom of Choice
Truth Telling
PROTECTION OF PRIVACY/CONFIDENTIALITY - HIPAA
Protection from discrimination
Protect the public welfare and protect the confidentiality of the individual
Social Justice in health care policy (ACA)

Epidemiology and levels of prevention

What is epidemiology?
Epidemiology is the study of health in populations to identify and understand the causes and patterns of health and illness
Looks at incidence and prevalence
The factors or "determinants" involved

Epidemiologic evidence

Called observational studies. The researcher does not manipulate but rather watches and observes
Cross Sectional Study: Take a group with a disease and one without and determines what characteristics or risk factors may have led to development of disease
Cohort or longitudinal study: Follow a group either through observation or through an exposure or dependent variable such as a treatment or intervention
Case Control: Work backwards with a group with disease and see what exposures occurred.

Epidemiology

Provides the science and structure for the framework in meeting the primary, secondary and tertiary needs of a population.

Human body
Physical, chemical or biologic element that causes the illness or the injury
Biggest variable as it includes the physical environment and the social environment like poverty, race, access etc.

Social Determinants of Health

According to the WHO, those factors which define our birth, the way we grow, live and die
Socio-economics
Neighborhood
Environment
Access to care
Access to other services
Education
Culture

Infant mortality

In the United States the infant mortality rate is the lowest in ranking of 27 developed countries (lower than Cuba)
US spends more money on health care than any other nation
Some rationale for accounting of premature births which would called miscarriage or stillbirths in other countries but only about 40% contributed explained to this (Ingraham, 2014)
What is the other 60%?????
Alabama 8.7 Same as Lebanon, Mississippi 9.6 Same as Botswana
Disparity between the states
Increase risk in Poor, uneducated, unmarried, limited access to care,
But what about other things ?

Upstream and downstream interventions

The Fence or the Ambulance

Levels of Prevention

Relationship between these levels are the basis of community health
Levels of prevention are meant to protect from disease

Pre pathogenesis Pre disease
Pathogenesis Disease/Injury/Disability
Goal is to intervene before at the earliest possible stage to prevent complications, limit disability and stop any irreversible changes
Primary Prevention - What is it?
Interventions aimed at preventing disease, injury or disability
Aimed at those who might be susceptible but show no signs of disease. Strengthen the host
Call be aimed at general population as well
Health Promotion, specific protection
Examples
Sun screen
Healthy eating
Exercise
Smoking cessation
Safe sex
Bike and Motorcycle helmets
Immunizations
Secondary Prevention - What is it?
Interventions that increase the probability of a person with disease will be diagnosed at time when treatment for cure is likely/possible
Interventions which increase early detection
STOP the process
Identifying if there is a disease
Examples
Mammograms
Colonoscopy
Statin therapy after MI - will prevent another MI from occurring. Another event. Not an extension of the MI
Be careful especially with cancer
Screenings - like Pap smear
Tertiary Prevention - What is it?
Interventions to limit disability
Arrest progress of established disease
Interventions which occur when changes are irreversible
Control negative consequences
Focus on rehabilitation
Restore to highest level/optimal level of function possible for the individual
Intervention that have occurred once someone actually has the process or the incident
Identifying that the disease existed but we want to prevent the extension of it
Stroke - PT
Examples
Physical therapy
Occupational therapy
Cardiac rehab
Can be follow care in chronic illness as well if disease remains permanent
Excellent definitions on page 268, 269 and 270 which provides one of those text boxes that provide information for learning and discuses screenings

Healthy people 2020

Started with Healthy People 1980
Promoting Health/Preventing Disease 1990
Healthy People 2000
Morbidity of health infancy, childhood, adolescence, adulthood, older age. Different metrics for different populations
Healthy People 2010
Improve health American people, increase years of healthy living and eliminate disparities among the populations
Healthy People 2020
Emphasizing ideas of health equity that address social determinants of health and promote health across all stages of life
• Replacing the traditional print publication with an interactive Web site as the main vehicle for dissemination
• Maintaining a Web site that allows users to tailor information `to their needs and explore evidence-based resources for implementation
Health Promotion ( Nutrition, ETOH, Family Planning, Mental health)
Health Protection (injuries, occupational environmental, food and safety, oral health)
Preventive Services ( maternal/infant, heart disease, cancer, DM, HIV, STD, Immunizations)
Surveillance and Data Systems
Increase numbers of years of quality living
Decrease health disparities (infant mortality, cancer, CV, DM, HIV, immunization)
467 objectives in 28 focus areas Objective the same for all people

Measurable and Developmental

Leading Health Indicators
Public Health Infrastructure
Healthy People 2020
Access to Health Care
Clinical Preventive Services
Environmental Quality
Maternal Child Health
Injury and Violence
Mental Health
Nutrition, Physical Activity, Obesity
Tobacco
Social Determinants
STD/Reproductive Health
Substance Use
LHI: Used to track the progress. Critical Public Health Demands

Determinants of health and health disparities

Healthy People
Encourages collaboration
Empowers individuals to make informed decisions
Measures impact of preventative measures

Transcultural nursing - Madeleine Leininger

Transcultural nursing
learned branch of nursing which focuses upon the study and understanding of cultures with respect to nursing and
health-illness
caring practices
beliefs
values with the goal to provide meaningful and effective nursing care services to people according to their cultural values and health-illness affecting them.
"Care that fit"
Madeline Leininger interview about Transcultural nursing on Youtube

Emic

Knowledge gained from direct experience or directly from those who have experienced.
It is generic or folk knowledge

Professional nursing care or caring

Formal and cognitively learned professional care knowledge and practice skills
Care is distinct, dominant, unifying and central focus of nursing, and, while curing and healing cannot occur effectively without care, care may occur without cure.Care and caring are essential for the survival of humans, as well as for their growth, health, well-being, healing, and ability to deal with handicaps and death.

Cultural imposition

Cultural imposition refers to efforts of the outsider, both subtle and not so subtle, to impose his or her own cultural values, beliefs, behaviors upon an individual, family, or group from another culture. (Leininger, 1978)
STOP and THINK
What is an experience you have had which was affected by culture?
How will your culture interfere with your care?
Give examples of culturally competent care

Role of Religion

All people are spiritual not all are religious
Be careful in making general assumptions of people based on stated denominations.
People who are religious in crisis
Effect of practice on health care, i.e. diet, life, death, organ donation, autopsy

Things to consider...

Who or what provides patient with strength and hope?
Does the patient use prayer in day today life?
How does the patient express their spirituality?
Philosophy of Life
What type of religious or spiritual help does the patient want ?
What does SUFFERING mean to the patient?
What does DYING mean?
Other things
How does patient cope with illness?
What lets them keep going day after day?
How has the illness affected patient and family?

Biologic Variations

HTN
Osteoporosis
Lactose Intolerance
Maturity/Puberty
HIV risk
STD risk
Sickle Cell
Infant Mortality rate Hispanic 5.00/1000 live births, Non Hispanic white 5.06/1000, Non Hispanic black 11.11/1000 (US Vital Statistics Report 2013)
African American women in Delaware who are insured and have same demographics as their white counterparts have increased infant mortality

Pitfalls to avoid

Stereotyping #1 Assuming all members have same values, norms beliefs
Presumption of common sphere of reference
Ethnocentrisms: Believing your own culture is superior to others
Cultural Imposition: Pushing your cultural beliefs on others.
Communication Misinterpretation
Prejudice: Preconceived ideas or beliefs, opinions about a group or culture that limit a full understanding of person gender or race. Do not limit to gender or race, can be towards anything/body
Discrimination: Denying a person or group opportunity, care or services
Cultural blindness: Refusing to recognize another's culture because of your own rigid cultural beliefs
Cultural Diversity: Can be "too politically correct", lose the uniqueness of the patient
Racism: Believing a human group is superior or inferior based on genetically transmitted trait
Judgmental Behavior
Fear and Apprehension

Things to think about

Good verses Excellent
Culturally competent care even more important when you are overwhelmed and busy
Cultural competence always changing, refining and expanding
Will be caring for patients on at all levels of acculturation, social classes and education---
Effect of money on culture

IOM report (institute of medicine)

Care is based on continuous healing relationships
Care is customized according to patients needs and values
The patient is the source of control
Decision is evidenced based
Needs are anticipated

Still thinking...

Culture, race and ethnicity not interchangeable topics.
Do not separate from your assessment
Keep questions more conversational
Explain to the patient why you are asking
Be direct, don't waffle and do not apologize.
Experience makes it all easier

Things to consider

Who is in charge?
Maslow Hierarchy of Needs
The patient
Nurse in community
Effective communication skills
Educational needs

Payne three voices

The child voice
The adult voice (allows for negotiation and for issues to be explained)
Parent voice (most nurses and educators speak in parent voice) (Payne, 2006, p. 82)

The nursing home visit

If the patient had a doctor appointment that day and you as the visiting nurse come to see the patient, it is most likely the visit will not be covered
To get home care, these patients have to be home bound. They may leave the house for doctor appointments or church, very little movement outside of home
To give health teaching regarding prevention and control of the disease which is part of your visit. Establish a close relationship and use of interprofessional relationships they have you may need to make arrangements for meals on wheel for food.
Say you have five visits for a newly diagnosed diabetic - what are the objectives for the visits:
First day would be to develop a relationship with them and to find out the safety piece and teach them how do they assess whether sugars are in order
Next visit can be doing the injections and then next visit could be the diets
Glucose monitoring
If they have one
Do they know how to use it
Do they understand what the levels should be
Diets
Who are their support person?
Be flexible as a home care nurse
http://nurseslabs.com/nursing-home-visit/
The first home visit
http://questgarden.com/137/38/1/111222110211/process.htm

BAPSCO

Foods containing potassium
Bananas
Apricots
Potatoes
Prunes
Spinach
Cranberries
Chicken
Orange juice

What is health literacy?

The Patient Protection and Affordable Care Act of 2010, Title V, defines health literacy as the degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions. (CDC, 2015)
How people communicate, understand and respond to health
Affected by beliefs, values, attitudes, traditions and language

The numbers

National Center for Education Statistics states that 88% of US population lacks the skills to maintain health prevention and disease.
14% have below basic health literacy (CDC, 2011)
75% born in the US, Half are not minority, 40% hold part time/fulltime employment and only 75% have a HS diploma
It is considered a vital sign - informed consent
Must be assessed with each encounter no matter what type of care you are providing
Can be dynamic and change with changes in patient's health.

Literacy vs Health literacy

Literacy
Ability to read
Use written materials to function
Reading, basic math, speech and speech comprehension
Health Literacy
Reading and Writing
Listening and Speaking
Understanding and working with numbers
Cultural knowledge
Able to apply concepts

Who is at risk

Elderly (age 65+) - Two thirds of U.S. adults age 60 and over have inadequate or marginal literacy skills, and 81% of patients age 60 and older at a public hospital could not read or understand basic materials such as prescription labels (CDC, 2010).
Minority populations
Immigrant populations
Low income - Approximately half of Medicare/Medicaid recipients read below the fifth-grade level
People with chronic mental and/or physical health conditions

Why?

Moving away from the "doctor knows best" model
Although empowering...difficult to navigate.
Medicare D- great example. According to Kaiser Foundation—only 13% understand their benefit
Associated with poorer utilization of preventive measures.
Lack of educational opportunity - people with a high school education or lower
Learning disabilities (not recognized as adults)
Cognitive declines in older adults
Use it or lose it - Reading abilities are often three to five grade levels below the last year of school completed. Therefore, people with a high school diploma, typically read at a seventh or eighth grade reading level.

Consequences

Increased use of emergency services
Over $73 billion dollars a year in excess expenditures
Exacerbations of chronic illness
Increased hospitalizations
Less likely to use prevention services
Shame in seeking care because does not know something
Art of caring, art of providing quality care to people especially to everyone but especially to those who are most vulnerable

Health literacy factors

https://health.gov/communication/literacy/quickguide/factsliteracy.htm

What is affected - individual?

Evaluate credibility and quality of care
Look at risk and benefits of treatment
Calculating doses of medications
Interpreting lab results ( cholesterol, A1c, glucose, BP readings)
Ability to locate information (label, internet, resources)
Read labels
Appointment reminders

Important to remember

Low literacy does not mean low intelligence!!
Health illiteracy affects everyone no matter their education, background, culture
A person can be very functional at work and home but be inadequate in health literacy
Important because we are "consumer centric" asking patients to take a more active role.
In the community, the patient is responsible for managing their own care

Health providers and health literacy skills

Help people find information and services
Communicate about health and healthcare
Process what people are explicitly and implicitly asking for
Understand how to provide useful information and services
Decide which information and services work best for different situations and people so they can act (CDC, 2015)

Who to consider

Is the information appropriate for the users?
Is the information easy to use?
Are you speaking clearly and listening carefully?

Best practice in health communication

Identify the intended users
Use pre- and post-tests
Limit the number of messages
Use plain language
Practice respect
Focus on behavior
Check for understanding
Supplement with pictures
Use a medically trained interpreter or translator

Target audience

Making your message fit the target audience is essential
Cultural Assessment again—the most important thing we do as nurses
Literacy level, community, interests, age, gender and on so and so on

What you need

Visual literacy
Computer literacy
Information literacy
Ability to calculate
Ability to communicate orally
Express worries and understand spoken advice

Health education in community nursing

Teaching the patient/ community
Reflects who you are teaching
Be aware of economic contexts
Life experiences
Culture of men/women
Traditional vs. Western medicine
Evaluate teaching before, during and after

Pedogogy vs Androgogy

The Learner
The learner is dependent upon
the instructor for all learning
· The teacher/instructor
assumes full responsibility for
what is taught and how it is
learned
· The teacher/instructor evaluates learning
The Learner
The learner is self-directed
· The learner is responsible for his/her own learning
· Self-evaluation is characteristic of this approach
Interpretative Pedogogy
Excellent example of patient teaching, addressing the target audience.
Not just using patient teaching materials but actually teaching the patient.
Adults Learn
When they think they need to know something
New information is compatible with what they know
They trust the person giving the information
They believe they can make the necessary changes that are being taught

Things to remember

Listen to the patient. What they want should be the foundation of what you teach.
Assess willingness to change
Be specific, teach the important things first
Keep to no more than 4 main ideas
Clarify often
Mutual goals, build on what the patient knows.
Some things to say?
"I want to be sure that I did not leave anything out that you need to know"
"Can you show me or tell me so I know that you understand what is important"
"What questions do you have for me"?
"Tell me about your problem? What may be causing your difficulties"?
How or What ....because with Why?

What are your barriers to patient teaching?

Public speaking
Lack of credibility on the topic
Limited professional experience
Can't engage?
Adjust instruction?
Need feedback

An Introduction - an overview of family nursing, family structure, family culture and family function

It is important for the CHN to understand and respect the unique characteristics, cultures, structures, and functions of the family?
Who is family?
What is family health?
Why work with the family on health issues?
1 Family nursing is a specialty area with a strong theory base. Nurses and families work together to promote family health, meet family health needs, and cope with health problems. Nurses must be aware of their own values and attitudes and be open to different structures and cultures.
2 Who do you say your Family IS?
3 Family AND health defined. Families are the context in which health care decisions are made. Families are responsible for managing or providing care to members. Family health refers more to mental health than physical health, and dysfunctional implies a bad family.

Family

"Two or more individuals who depend on each other for emotional, physical, and/or economic support" (Hanson and Boyd, 1996)
"Two or more individuals who share a residence or live near one another, possess a common emotional bond, engage in interrelated societal positions, roles, and tasks, and share a sense of affection and belonging". (Friedman, 1998)
Ask "Who does the client say is family?"
Legalistic concepts and "blood relatives" are narrow definitions
Societal definitions have changed
Members are self-defined
Who do you consider to be in your family?
Traditionally - relatives connected by "blood ties"
Legal concepts - Include adopted and guardians and marriage
Families are a unit. They operate as social systems and each member influences every other member.

Universal Characteristics

Each family is UNIQUE, but there are some UNIVERSAL Characteristics:
Is a small social system
Has its own cultural values and rules
Has structure
Has basic functions
Has a life cycle with stages

Healthy family characteristics

Positive interactions (relationships and communication)
Member development enhanced
Problems are actively addressed (coping)
Effective, structured role relationships
Home environment and lifestyle are healthy
Regular links with the broader community are established

Family structure

Characteristics and demographics of individual members of family units (Includes roles and relationships)
Shape, size, and composition of members along with age, gender, and number (Demographics)
There is NO typical family model
Is dynamic and changes over the development of the family and the career of the individual (stages)
Structure also defines the roles, value systems, communication processes, and power positions of family members. These elements are all interrelated and interacting.

Type of family structure

Married family (traditional nuclear, Stepfamily)
Single Parent Family (never married, formerly married but divorced or widowed)
Multi Adult Households (Cohabiting, Extended family, Same sex partners)
Traditional
An individual may move through several configurations of family structure in the course of a lifetime and experiences.
E.g. a child may grow from infancy to toddler in a married family, parents divorce and the child may spend time in a single parent family or multi adult household (live with grandparents). If one or both parents remarry the structure is stepfamily. The child grows to adulthood and may choose to cohabitate or marry. Etc.
Most familiar and readily accepted
All in same household
Nuclear family (husband, wife, child(ren)
Nuclear dyad (husband, wife,)
Single adult - single parent
Multigenerational
Variants: Kin-network, blended, commuter family
Nontraditional or Contemporary
Some are becoming more common - unmarried, cohabiting, communes, same sex
Some are generally accepted
Foster families
Others regarded as illegitimate
group marriage, gay marriage??
Dangerous - gangs

Older American Ideals

to marry
to remain married
to have children
to restrict intimate relations to marriage
to maintain separate roles for male and female
Since 1950, changes have occurred in the family structure, values and forms, largely due to weakening in American ideals.

Categories and Emerging Patterns

Marriage/Remarriage
Divorce
Multiple Births
Cohabitation (Adolescent Unmarried Parents)
Single parents
Grandparent households
Gay and lesbian families

Family Functions - Traditional

As economic units to achieve financial survival
To reproduce the species
To provide protection
Pass along culture (including religious faith)
Educate and socialize offspring
Historically, families who performed all of these functions were considered healthy and good.

Essential Family Functions today

Providing affection
Providing security
Instilling identity (satisfaction)
Promoting affiliation (companionship)
Providing socialization
Establishing controls

Stages of the family life cycle

As the family grows and develops and encounters crises, changes occur:
Includes roles, composition, and relationships over time
Broad stages - Expansion then Contraction
Phases include launching of children and retirement of parents

Family assessment

Families are complex
Each family is unique in its combination of structure, composition, roles, and behaviors.
As long as it functions effectively and demonstrates the characteristics of a healthy family, its form is valid
Families are constantly changing
Family Assessment Approaches
Genogram
Multigenerational pictorial of health
Ecomap
Each of the first three approaches is unique and produces a different data base from which to plan interventions.
They can be used alone or in combination.

Assessment categories

Demographics
Physical environment
Psychological and spiritual environmt
Structure and roles
Functions
Values and beliefs
Environmental Data
Housing structure, safety, hazards
Neighborhood urban, rural, homeless, physical, social, demographic

Family health

Family Roles
Through the performance of family roles the family functions are fulfilled
Role is defined as the set of behaviors (assigned or assumed) that are performed by a member of a given social position in day to day living
Some may be culturally defined or extend beyond immediate family (work, school)
Some roles are shared
Intra-role functioning - play several roles at the same time
Every individual occupies multiple positions.
E.g. Adult, male, husband, father, farmer, etc.

For each position is a number of roles, e.g.
the HUSBAND position may have associated roles of breadwinner, handyman, protector.
The FATHER position may have associated roles of disciplinarian, coach, rule maker, etc.

Individuals enact particular roles based on societal expectations but modified by identification with role models and individual personality characteristics (temperament, attitudes, motives, and capabilities).

Family roles in illness

Mother family health leaderprimary caregiver
Role changes and family structure modification occurs during a crisis
Family Values
Sometimes unspoken or outside of conscious awareness
Powerful determinants of what the family feels, thinks and does
Influences the family view of education, healthcare, lifestyle, courtship, marriage, child rearing, sex roles, etc.

More Assessment categories

7. Communication patterns
8. Decision-making patterns
9. Problem solving patterns
10. Coping patterns
11. Health behaviors
12. Social and cultural patterns

Communication patterns

Defined: the process of exchanging feelings, desires, needs, information, and opinions
Includes verbal and non-verbal
One of four dimensions of family structure (Friedman)
Functional vs dysfunctional implies mental health but also refers to family communication, and what works or does not.
Comes from the 4 structural dimensions of the family system as outlined by "Friedman"
1 communication
2 power structure
3 role structure
4 values and norms

Factors that influence communication

Context/Situation
Ethnicity
Family Life Cycle
Gender
Family Structure
Socio-economic status
What is the immediate context in communication takes place?
Communication is embedded in a matrix of beliefs and patterns, many of which are culturally derived. E.g. Americans encourage verbally explicit messages, Navajo and Chinese value silence. Expression vs restraint. Conflict: Americans tolerate disagreement, Mexicans and Japanese tolerate less.
Communication is altered with an individuals longevity and experiences
Communication in females is generally more expressive, sensitive and clearer and see communication as building bridges. Males see it as a demonstration of status and knowledge.
Comfort levels and familiarity in the structure -
e.g. stepfamily communication

Elements of family communication

Includes all behavior
Content + Command
Punctuations
Negative and Positive feedback loops
Redundancy principle
Symmetrical or Complementary
All behavior is communication
A message contains 2 levels, the context of what is said coupled with a command
Punctuations involve interpreting the situation in which the communication is conveyed.
Negative feedback is positive and productive because it corrects or adjusts to the information flow. Positive feedback is negative because it continues in the same direction to the point that the deviation causes self destruction. E.g. and escalating argument.
Patterns of communication in families are repeated, give evidence that "rules" of commuication operate in families.
Summetrical - mirrors the behavior of the other and Complementary - each supplements the other

Power and Decision making - variables affecting the power structure

The power heirarchy
Type of family structure/form
Formation of coalitions
Communication network
Gender differences
Age and family lifecycle
Cultural and interpersonal factors
Social class
Healthy vs. Family Violence

Power distribution

The possession of control, authority, or influence over others assumes different patterns in each family
Absolute, patriarchal, dominant
Distributed, shared, egalitarian
Often influenced by roles (responsibilities and authority attached)

Socio-cultural assessment

Culture and ethnicity
Social class: upper, middle, lower, working
Economic status: income level and source of income education and occupation
Composition depicted in the Genogram

Family culture

Culture is acquired knowledge, sometimes transmitted by previous generations, religious influences, or the larger society. Family members use it to interpret their experiences and to generate behaviors that influence structure and function.
Culture explains why families behave as they do (Leininger, 1991)
Right to self determination if the patient refused any assistance such as a home health aide to provide care
Know the need and know how that need is going to be funded
Two big area of concern is the bathroom and the kitchen

Genogram

A three generation family tree format that depicts the family members and their relations over time.
Shows important family historical patterns and health information
An essential component of assessment to be used concurrently with any of the previous 3 models.
It is a diagram, a skeleton, a constellation showing the structure of intergenerational relationships.
It is used for planning intervention strategies because it displays the family visually and graphically in a way that provides a quick reference and overview of family complexities.

Completing a genogram

Symbols describe family membership and structure - Male, female, birth, death, children, etc.
Family interaction patterns are depicted by lines that join the symbols - Marriage, divorce, close relationship, conflicting, distant, etc.
See text sample p 498 and 499. Or give handouts Fig 7-4.

Standard symbols for a genogram

http://courses.wcupa.edu/ttreadwe/courses/02courses/standardsymbols.htm
Index person or the pro-ban in which the person in which the genogram is derived from
This provides symbols that show the relationship between the members f the genogram.

Outline for a genogram interview

Names
Ages and dates of birth
Cause and date of deaths
Dates of marriages, divorces, separation,etc
Occupations and Educational levels
HEALTH PROBLEMS
Significant life events (crises)

Genogram interpretive categories

The following areas are important to observe in a family genogram:
Family structure
Sibling subsystem
Pattern of repetition
Life events

Example of an genogram

Genogram
Medical symbols
Red equal heart attach
Green equals diabetes
Blue outline indicates smoking
Purple equals breast cancer
Gray equals depression
Blue equals downs syndrome.
Navy downs syndrome
Questions
Who died from a heart attach
Who in the family are smokers
Which family member has a child with Downs syndrome
Who has breast cancer
Who is pregnant has breast cancer and is suffering from depression
Are there any patterns in this genogram
Review of Genogram
Using information in slide 36 Evaluate the genogram
What information are you able to gather regarding this family?
Are there any repeating factors ?
How would you add medical information to this genogram.

Ecomap

A visual representation of the family unit in relation to the community around it
An organizational tool that show relationships between family members and subsystems
Shows the direction of energy flow from the family or into the family
Uses a genogram and then looks at the social systems that evidence the family

Setup of an ecomap

Large central circle - Family genogram
Smaller outer circles - Significant people, agencies, institutions in the family's context
Lines are drawn between the circles and the family members to show the nature and quality of relationships and RESOURCES available
Ecomap exercise
http://barefootsocialwork.weebly.com/uploads/3/9/7/4/39743910/ecomap_activity.pdf

Transitions of care

Uninsured, underinsured, and limited services
Social and family policy challenges
Historically, family demographics can be analyzed by looking at data about the families and household structures and the events that alter these structures. Nurses draw on family demographic data to forecast and predict family community needs, such as family developmental changes, stresses, and ethnic issues affecting family health, as they formulate possible solutions to identified family community problems.

In 2007, in the United States, there were more than 11.2 million households, with 67% being family households and the remaining 33% being nonfamily households. Family households include a householder and at least one other member related by birth, marriage, or adoption; a nonfamily household is either a person living alone or a householder who shares the house only with nonrelatives, such as boarders or roommates.
Improved communication = better outcomes
What helps achieve this?
Nurses' hours match family schedules
Family member bringing companion to office visits
Enhances shared decision making
Improves sharing of information
Involving family in client's care
Improves self-management of care
Results in fewer medication errors
Improves health outcomes
Uninsured, Underinsured, and Limited Services

Definition of family

Definition used by family system and family nurses
Family refers to two or more individuals who depend on one another for emotional, physical, or financial support; the members of the family are self-defined.
Definitions are broadening as nontraditional families increase.
Now more than ever, the traditional definition of family is being challenged with the legalization of same-sex marriages.

Public health nurses and family nurses struggle on a daily basis with the conflict between the narrow traditional legal definition of family used in the health care system and by social policy makers and the broader term used by the family.
Definitions are broadening as the numbers of nontraditional families increase.

Now more than ever, the traditional definition of family is being challenged with the legalization of same-sex marriages.

Public health nurses and family nurses struggle on a daily basis with the conflict between the narrow traditional legal definition of family used in the health care system and by social policy makers and the broader term used by the family.

Role of communication

Nurses play pivotal role in communication among health care agencies and between agencies and the client's home.
Problems with communication
Incomplete or missing documentation from rushed assessments
Low health literacy levels
Failure to use current evidence-based practices
Consequences of poor communication
Higher risk of readmission
Poorer outcomes

Goals of affordable care act (ACA)

Provide patient protection.
Ensure availability of affordable health care.
Decrease the overall cost of health care.
The remaining uninsured
Undocumented immigrants
Citizens who choose not to enroll in Medicaid
Residents of states that opt out of Medicaid Expansion provision (voluntary program)
Uninsured clients are those who do not have health insurance for any family member.
Underserved are individuals who have minimal insurance coverage and usually have a high deductible.
Individuals with limited services are people who may have troubling accessing health care or experience barriers to health care.

Family Functions and Structures

Ways in which families meet the needs of—
Each family member
The family as a whole
Their relationship to society
Family functions
Economic function
Reproductive function
Socialization function
Affective function
Health care function
Family Structure
Member characteristics and demographics
Age, sex, number, and so on

Factors in determining family structure

The individuals who compose the family
The relationships between them
The interactions between the family members
The interactions with other social systems
Family structures have changed over time to meet the needs of the family and society. The great speed at which changes in family structure, values, and relationships are occurring makes working with families at the beginning of 21st century exciting and challenging.

Family Demographics

Living arrangements
Marriage, divorce, and cohabitation
Births
Parenting
Immigration
Family caregivers
Historically, family demographics can be analyzed by looking at data about the families and household structures and the events that alter these structures. Nurses draw on family demographic data to forecast and predict family community needs, such as family developmental changes, stresses, and ethnic issues affecting family health, as they formulate possible solutions to identified family community problems.

In 2007, in the United States, there were more than 11.2 million households, with 67% being family households and the remaining 33% being nonfamily households. Family households include a householder and at least one other member related by birth, marriage, or adoption; whereas a nonfamily household is either a person living alone or a householder who shares the house only with nonrelatives, such as boarders or roommates.

Living arrangements

Number of households tripled since 1940
Largest growth: people living alone
Higher life expectancy = more single-person households
Impact on health care
Single individuals may delay seeking care.
Transportation (especially with older singles) may be a problem.
Isolation (living farther away from other family members who could help)
Cohabitation is a couple living together who are having a sexual relationship without being married.

Marriage, Divorce and Cohabitation

Higher age for first marriage
Divorce rate for people 50 years or older doubled between 1990 and 2010
Increased occurrence of cohabitation
Potential for negative child well-being
Parental separation 5 times more likely than for married couples
Increase in unstable living situations (higher number of transitions)
Higher rate of poverty in cohabitating families
Cohabitation refers to a couple living together who are having a sexual relationship without being married.

Birth

Fertility rates differ by race and ethnicity.
Not all cultures value limiting the number of children in a family.
Increase in mother's age at first birth
Average is 25.4 years of age
Substantial increase in number of children born outside of marriage

Parenting

Increasing number of nontraditional roles
Blended households
Single (never married) mothers
Divorced mothers
Single fathers
Grandparents raising grandchildren
Single mothers, never married, are particularly disadvantaged; they are younger, less well educated, and less often employed than are divorced single mothers and married mothers (Casper et al, 2015).
Mothers who never married (25%) are much less likely to get child support from the father than are mothers who are divorced or separated (43%) (Casper, Florian and Brandon, 2015).
Divorced mothers are substantially better educated and more often employed than are mothers who are separated or who never married.
However, the average incomes of families headed by divorced mothers is less than half that of two-parent families (Casper et al, 2015).

Immigration

In 2010, 20% of all U.S. births were to mothers born outside the country
Illegal immigrants
Do not qualify for public benefits
Do not qualify for health care
Nurses need the following:
Strong cultural literacy
Strong knowledge of cultural health beliefs

Family Caregivers

Family caregivers: 30% of American adults
Most provide care for someone 50 or older
Most are themselves over 50 (12% older than 65)
Growing trend: children as caregivers
Affects children's health and school performance
Nurses can work with families who are providing care to their family member in the following ways (National Alliance for Family Caregiving, 2009):
Identify and help caregivers who are most at risk for deteriorating health, financial security, and quality of life so that they can continue to provide care while maintaining their own well-being.
Identify and advocate for programs that make a real difference in caregivers' well-being and in their ability to continue providing care.
Identify and promote the use of technologies that can facilitate caregiving.
Extend the reach of caregiver programs to all caregivers regardless of the age of their care recipient.
Encourage families to plan proactively for aging and potential health/disability issues.

Family Health

A dynamic relative state of well-being that includes the biological, psychological, spiritual, sociological, and cultural factors of the family system
Holistic approach
Dysfunctional families
Balanced families
Family flexibility
Family cohesion
A popular term for nonhealthy families is dysfunctional families, also called noncompliant, resistant, or unmotivated—phrases that label families that are not functioning well with each other or in the world.
Families are neither all good nor all bad; rather, all families have both strengths and difficulties. All families have seeds of resilience and strengths upon which the nurse should work with the family to build interventions and design plans of action. Nurses should view family behavior on a continuum of need for intervention.
Families with strengths, functional families, and balanced families are terms often used to refer to healthy families that are doing well.

Theories for working with Families in the community

Family systems theory
Families are social systems; thus, nurses can learn much from a systems approach.
Family development and life cycle theory
Focuses on predicted stresses of families as they change and transition over time

Working with Families for healthy outcomes

Collecting pre-encounter data
Determining where to meet the family
Making an appointment with the family
Planning for your own safety
Interviewing the family: defining the problem
Family assessment instruments
Family health literacy
Designing family interventions
Evaluating the plan

Collecting pre-encounter data

Actual or potential problem identified
Possible sources
Family, physician, school nurse, caseworker
Pre-encounter data
Referral source
Family
Previous records

Determining where to meet

Before contacting the family to arrange for the initial appointment, the nurse decides the best place to meet with the family.
Home
Clinic
Offic

Making an Appointment

Assessment is reciprocal.
Introductions: explain the purpose
Do not apologize.
Arrange a time that is—
Convenient for all parties
Allows the greatest number of family members to be present
If appropriate, offer an interpreter.
Confirm appointment.
Place, time, date, and directions
Data collection starts immediately upon referral to the nurse. These are suggestions that will make the process of arranging a meeting with the family easier.

Planning for your own safety

Leave a schedule at your office.
Plan the visit during safe times of day.
Dress appropriately.
Avoid secluded places.
Obtain an escort.
Sit between the client and the exit.
If you feel unsafe, do not visit or leave immediately.
Check in with work at the end of the day.
It is critical to plan for your own safety when you make a home visit. Learn about the neighborhood you will be visiting, anticipate needs you may have, and determine if it is safe for you to make the home visit alone or if you need to arrange to have a security person with you during the visit. Always have your cell phone fully charged and readily available. In addition, these strategies will help to ensure your own safety when you visit families in their homes.

Interviewing the family

Start informally.
Involve each family member.
Shift to formal interview
Ask family to share their story
Recall your purpose.
To gather information
To help the family focus on their problem
To help determine solutions
The following specific therapeutic questions have been found to provide important family information:
What is the greatest challenge facing your family now?
On which family member do you think the illness has the most impact?
Who is suffering the most?
What has been most and least helpful to you in similar situations?
If there is one question you could have answered now, what would that be?
How can I best help you and your family?
What are your needs/wishes for assistance now?
Box 27-3 lists a variety of additional interview questions that will help uncover the family story.
look at page 610 of public health nursing

Family Assessments instruments

Assessment tool qualities:
Uncomplicated language (fifth-grade level)
Takes 10 to 15 minutes to complete
Relatively easy and quick to score
Renders valid data for decision making
Diversity sensitive
Genograms
Ecomaps
The genogram displays pertinent family information in a family tree format that shows family members and their relationships over at least three generations. The genogram shows family history and patterns of health-related information, which is a rich source of information for planning interventions. The identified client and his or her family are highlighted on the genogram. Genograms enhance nurses' abilities to make clinical judgments and connect them to family structure and history.
The ecomap is a visual diagram of the family unit in relation to other units or subsystems in the community. The ecomap serves as a tool to organize and present factual information and thus allows the nurse to have a more holistic and integrated perception of the family situation. The ecomap shows the nature of the relationships among family members and between family members and the community; it is an overview of the family, picturing both the important nurturing and the important stress-producing connections between the family and its environment.

Ecomap

Family unit in relation to other units or subsystems in the community

Family Health Literacy

Functional health literacy techniques
Use black ink on white paper.
Use short sentences.
Use bullets no longer than seven items.
Write information at the fifth-grade reading level.
Remove all extra words.
Print in upper- and lowercase letters.
If using a computer, use 14-point font with a high-contrasting Arial (or other sans serif) typeface.
Have plenty of white space.
Rather than spend time determining the extent of the health literacy in a family, it is most important that nurses employ these techniques when writing out plans of care, listing directions, discussing medication management, or writing telephone numbers.
Families retain more information when nurses use a variety of communication methods, including both visual materials and visual language. Families need direct clear information to assist in their decision making and carrying out the plans of action.

Social and Family Policy Challenges

Family policy
Social policy
Health care access and coverage, low-income housing, social security, welfare, food stamps, pension plans, affirmative action, and education
Family medical leave (1993)
Debate as to what constitutes a family
Teen pregnancy prevention
Health care insurance
Affordable Care Act (2010)

Early Approaches to Family Health Risks

Health of families
Health of the nation
Health of Families
Effect of illness on families
Role of family in the cause of disease
Role of family in its use of services
Health of the Nation
Shift from infectious disease to chronic disease as leading cause of death
Link between lifestyle and health
Link between heredity and lifestyle/environment
Surgeon General's Report on Health Promotion and Disease Prevention (1979)
Healthy People 2020

Concepts in Family Health Risk

Family health
Health risk
Health risk appraisal
Health risk reduction
Family crisis
Pender's health promotion model, described in the latest 2010 edition of her textbook, continues to be useful in research that is done with families. This health promotion model states there are two factors that motivate individuals to participate in positive health behaviors. One is a desire to promote one's own health, using behaviors that have been determined to increase the individual, family, community, and society's well-being, and in the process, actually moving toward not only individual self actualization, but a society actualization as well. The second factor is a desire to protect health, using those same behaviors in an effort to decrease the probability of ill health and provide active protection against illness and dysfunction in families. Understanding family health risk requires an examination of several related concepts: family health, family health risk, risk appraisal, risk reduction, life events, lifestyle, and family crisis.

Family Health

Neuman systems model
Family health is defined in terms of system stability as characterized by five interacting sets of factors:
Physiological
Psychological
Sociocultural
Developmental
Spiritual
Health Risk
Inherited biological risk
Age-related risks
Social and physical environment risks
Environmental risks
Social aspects
Physical aspects
Behavioral risk

Quick Recall 1

Which of these risks are inherited? (Pick two)
A. Age-related risks
B. Physical aspects
C. Social aspects
D. Social and physical environment risks
Answer is A and D
How'd You Do?
Inherited biological risk
Age-related risks
Social and physical environment risks
Environmental risks
Social aspects
Physical aspects
Behavioral risk

Health Risk Appraisal

Assessing for factors associated with an increased likelihood of an unhealthy event
For example, illness, such as cancer, or an unhealthy event, such as an automobile accident
Youth Behavioral Health Risk Appraisal instrument (Centers for Disease Control and Prevention [CDC], 2010)
Health Risk Reduction
Based on the assumption that decreased risk (in number or magnitude) lowers probability of an undesired event
Pender (2010) provides examples of different kinds of risks:
Voluntarily assumed risks are better tolerated than those imposed by others.
Risks over which scientists debate and as a result have some level of uncertainty as to their magnitude are more feared than risks on which scientists agree.
Risks of natural origin are often considered less threatening than those created by humans.
Risk reduction is a complex process that requires knowledge of the specific risk and the family's perceptions of the nature of the risk.

Family Crisis

Family lacks or loses the ability to cope with a specific event or multiple events and becomes disorganized or dysfunctional
Demands of the situation exceed the resources of the family
Major Family Health Risks and Nursing Interventions
Healthy People 2020 target areas
Health protection activities
Family health risk appraisal
Biological and age-related risk
Biological health risk assessment
Environmental risk
Environmental risk assessment
Behavioral (lifestyle) risk
Behavioral (lifestyle) health risk assessment
Healthy People 2020 targets areas in health promotion, health protection, preventive services, and surveillance and data systems to describe age-related objectives (U.S. Department of Health and Human Services [USDHHS], 2010). Included in the area of health promotion are physical activity and fitness, nutrition, tobacco use, use of alcohol and other drugs, family planning, mental health, mental disorders, and violent and abusive behavior. Health protection activities include issues related to unintentional injuries, occupational safety and health, environmental health, food and drug safety, and oral health. Preventive services, designed to reduce risks of illness, include maternal and infant health, heart disease and stroke, cancer, diabetes, and other chronic disabling conditions, human immunodeficiency virus (HIV) infection, sexually transmitted diseases, immunization for infectious diseases, and clinical preventive services. The interrelationships among the various groups of risk are clear when the objectives for the nation are considered. Most of the national health objectives are based on risk factors of groups or populations in a variety of categories like age, gender, or health problem. However it is important to recognize that some of these factors also relate to and have potential effects on the individuals' families, work, school, and communities.

Nursing Approaches to Family Health Risk Reduction

Home visits
Contracting with families
Empowering families
Home Visits
Give a more accurate assessment of the following:
Family structure
Natural or home environment
Behavior in that environment
Provide opportunities to do the following:
Identify barriers.
Identify supports for reaching family health promotion goals.
Home Visit Process
Initial phase
Pre-visit phase
In-home phase
Termination phase
Post-visit phase

Five skills for effective home visits

Observing
Listening
Questioning
Probing
Prompting

Contracting with families

Working agreement that is continuously renegotiable and may or may not be written
Contingency contract
Noncontingency contract
Process
Beginning phase
Working phase
Termination phase
Advantages and disadvantages

Empowering families

Helping individuals and families assume an active role in promoting their health care
Access and control over needed resources
Decision-making and problem-solving abilities
Ability to communicate in order to obtain needed resources

Community Resources

Telehomecare
Family policy
Family and Medical Leave Act (FMLA) (1993)
Vulnerable population:
Lesbian, gay, bisexual, transgender, and queer (LGBTQ) families at risk
Home Care National Patient Safety Goals
https://www.jointcommission.org/assets/1/6/2016_NPSG_OME_ER.pdf

Healthy People 2020

Healthy People 2020 provides a comprehensive set of 10-year, national goals and objectives for improving the health of all Americans.
Strides made
Life expectancy at birth increased
Rates of death from coronary heart disease and stroke decreased
Leading Health Indicators
Public health challenges remain, and significant health disparities persist.
There are 26 leading health indicators
Examples of leading health indicator topic
Access to health services
Maternal infant and child health
Mental health
Grossly underfunded
Oral health
Substance abuse
Physician induced drug epidemic
There are ways in which physicians and healthcare providers can prescribe medication with regards to pain control
Injury and violence
Health People 2020 exploration
Go to the following
https://www.healthypeople.gov/

Culture of Health

Culture of Health Risa Lavizzo Mourey
https://www.youtube.com/watch?v=rs4QSF6mxug
Supplemental viewing
Culture of Health Risa Lavizzo Mourey
https://www.youtube.com/watch?v=h6N8D70yOqk
Robert Wood Johnson Culture of Health
http://www.rwjf.org/en/how-we-work.html
Culture for Health
https://www.youtube.com/watch?v=XeIfRaKqDnw
Robert Wood Johnson https://www.youtube.com/watch?v=ERNgoxvikAo
Culture of Health
https://www.youtube.com/watch?v=0H9OYuUi85c
Culture of Health
Childhood of obesity
Receive the best of Health Care benefits
Involvement of businesses in the community they serve
Reduction of Violence
Zip code may make more of a difference than genetic code in determining health

Healthy People 2020: Educational and Community Based Programs

Emphasis: health status, longevity, quality of life
High school completion; school health education
Undergraduate health risk behavior information
Work-site health promotion; participation in employer-sponsored health promotion
Patient satisfaction with health care provider communication
Community-based health promotion
Culturally appropriate health education
Senior health education

Cultural Sensitivity

Nurses need to develop an educational plan that is best suited to the individual or group.
Awareness of biases and stereotypes
Understanding of the populations health literacy
Disease process
Prevention actions and strategies that are culturally acceptable
Diversity and Health
https://www.youtube.com/watch?v=Z52SSqa8t1k (3min)

Models for change

Health Belief Model (Stanhope pg. 366)
Rosenstock model of Patient compliance
Most patient action taken on their health are based on the individual perception of the situation at hand.
Albert Bandura Social Cognitive Theory of Self Efficacy
The Individuals confidence in his/her ability to be successful is an endeavor.

Components for patient to learn

Ability
A sensory image on how to carry out (i.e. doing a dressing change or administering insulin)
An opportunity to practice the skill (i.e. practicing the psychomotor skill)

Elements of Practice Commonly Associated with Community Health Nurses
Aggregate focused care

Holistic approach to care
Use of public health principles of health promotion
Promotion of client self care.

Community Health Nurses

Community health nursing is autonomous
Paramount characteristic is collaboration
In primary prevention the primary role of the nurse is education.

Health Promotion Through Change

PHN educator: goal of effecting change in people's behavior
Changing behavior
Many different reasons for change
Attempts and failure several times before success
Working at some changes possibly lifelong
Most change on own without special programs
People different; what works for one may not work for another

Planned Change Models

Planned Change
Purposeful and intentional
Change by design not default
Improvement as the aim for planned community health change
Accomplishment through an influencing agent

Question

Is the following statement True or False?
Individuals often have similar motives or reasons for change.
Answer: False
Rationale: People decide to change for many different reasons.

Stages of change

First described by Kurt Lewin
Stages:
Unfreezing (when desire for change develops)
Changing/moving (when new ideas are accepted and tried out)
Refreezing (when the change is integrated and stabilized in practice)
Kurt Lewin's Theory of Change
https://search.yahoo.com/yhs/search?p=video+on+kurk+lewins+theory+of+change+&ei=UTF-8&hspart=mozilla&hsimp=yhs-001

Planned changed

1.Recognize symptoms
3. Analyze alternative solutions
5. Plan the change
7. Evaluate the change
2. Diagnose need
4. Select a change
6. Implement the change
8. Stabilize the change
Planned Change Strategies
The normative-reeducative: strategy involves new information that directly influences people's attitudes and behaviors through persuasion.
Empiric-rational: strategies are used to effect change based on the assumption that people are rational and when presented with information will adopt new practices that appear to be in their best interest.
Power-coercive: strategies use coercion based on fear to effect change.

Question

Which of the following characterizes normative re-educative strategies for change?
A. Persuasion
B. Coercion
C. Rationality
D. Best interests
Answer: A. Persuasion

Principles for effecting positive change

Participation
Resistance to change
Proper timing
Interdependence
Flexibility
Self-understanding

Social determinants of health

Factors that influence an individual's ability to maintain good health include social, economic, and physical factors such as:
Access to social and economic opportunities
Safe housing
Quality education
Clean water, food, and air
Safe workplaces
Equitable social interactions
Adequate community resources

Domains of learning

Cognitive: mind and thinking processes
Knowledge (recall, knows) states that insulin will control own diabetes
Comprehension (Understands) describes insulin action
Application (uses learning) adjust insulin dosage
Analysis (explains) discusses relationship between insulin diet and exercises and diabetic control
Synthesis (generates new ideas) develops a plan
Evaluation (compares objectives and outcomes)
Affective: emotion, feeling, affect
Receptive~ Active participants~ Acceptance/commitment
Psychomotor: visible demonstration of performance skills requiring some type of neuromuscular coordination

Bandura Social Learning Theory

Learning Theories: Behavioral

Stimulus-response
Pavlov: Certain causes evoke certain effects.
Conditioning
Skinner: conditioning with reinforcement

Learning Theories: Cognitive

Jean Piaget
Assimilation
Accommodation
Adaptation
Gestalt-field
Insight theory
Goal-insight theory
Cognitive field theory

Question

Is the following statement True or False?
Skinner is a behavioral theorist who used conditioning with reinforcement.
Answer: True
Rationale: Skinner is a behavioral theorist who addresses conditioning with reinforcement, such that successive systematic changes in a learner's environment enhance the probability of the desired response.

Learning Theories Humanistic

Abraham Maslow
Hierarchy of human needs
Physiologic safety and security love and sense of belonging self-esteem self-actualization
Carl Rogers
Self-directed
Client centered, warm, positive, & empathetic

Knowles's Adult Learning Theory

Adult learners different from children
Characteristics of adults with implications for learning
Self-directed
Life experience
Readiness to learn
Problem-centered time perspective

Health Teaching Models

Health Belief Model (HBM)
Readiness to act on behalf of a person's own health predicated on 6 concepts (perceived susceptibility; perceived seriousness; perceived benefits of action; barriers to taking action; cues to action; self-efficacy)
When is this person ready for change? Need that readiness or action for change
Through self effiacy, we can teach client skills and provide them support and they can make the changes for themselves
Health Teaching Models (continued)
Pender's Health Promotion Model (HPM), revised
Individual characteristics and experiences
Behavior-specific cognitions
Behavior outcomes
PRECEDE and PROCEED Models
Predisposing, Reinforcing, and Enabling Constructs in Educational/Ecological Diagnosis and Evaluation
Policy, Regulatory, and Organizational Constructs for Educational and Environmental Development
PRECEDE-PROCEED Model
http://ctb.ku.edu/en/table-contents/overview/other-models-promoting-community-health-and-development/preceder-proceder/main

Question

Which of the following health teaching models explains the behaviors and actions taken by people to prevent illness and injury?
A. Health Belief Model (HBM)
B. Health Promotion Model (HPM)
C. PRECEDE model
Answer
A. Health Belief Model (HBM)
Rationale: The HBM is useful for explaining the behaviors and actions taken by people to prevent illness and injury.
The HPM includes three general areas: individual characteristics and experiences, behavior-specific cognitions, and behavioral outcomes.
The PRECEDE Model involves social, epidemiological, education/ecological assessments followed by administrative and policy assessment and intervention alignment, and implementation.

Teaching Methods and Materials

Formal or informal, planned or unplanned
Methods
Lecture
Discussion
Demonstration
Role-playing
Materials (visual images, anatomic models, equipment, printed support materials, examples)
Content, complexity, reading level, culturally appropriate

Clients with special learning needs

Cultural or language differences
Hearing impairments
Developmental delays
Memory losses
Visual perception distortions
Problems with fine or gross motor skills
Distracting personality characteristics
Demonstrations of stress or emotions

Questions

Is the following statement True or False?
Assessment and diagnosis is the first step in the teaching process.
Answer: False
Rationale: The first step in the teaching process is interaction, establishing basic communication patterns between clients and nurse. Assessment and diagnosis follows.
Healthy Cities/Healthy Communities
http://ctb.ku.edu/en/table-of-contents/overview/models-for-community-health-and-development/healthy-cities-healthy-communities/main
Windshield Survey
http://ctb.ku.edu/en/table-of-contents/assessment/assessing-community-needs-and-resources/windshield-walking-surveys/main

Home Health Nursing

Home health nursing services enable individuals of all ages to remain in the comfort and security of their homes while receiving health care.
Family support, familiar surroundings, and participation in the care process contribute to feelings of worth and dignity.
Services may include skilled nursing, physical therapy, speech language therapy, occupation therapy, social services, intravenous therapy, nutritional support, home health aide, respiratory therapy, acquisition of medical supplies and equipment, and homemaker and companion care.
Who would be a candidate for home health care?
What are the benefits for the patient regarding home health care?

Home health care defined

Four Different Perspectives
Official
Services are provided to individuals and their families in their place of residence for the purpose of promoting, maintaining, or restoring health or of minimizing the effects of illness and disability.
Patient
Skilled and compassionate care is provided on a one-to-one basis in the comforting and familiar surroundings of the home.
Give examples of patients who would meet criteria for official and patient home health care.
Four Different Perspectives (continued)
Family
It is a means to keep the family together as a functioning, integrated unit.
Provider
All disciplines involved are challenged to provide excellent care in often less-than-excellent conditions and surroundings.

Historical overview

Home care was formerly defined as simply providing physical care to the sick in their homes, but the scope and complexity of the concept and practice have grown.
Roots of the concept can be traced to the New Testament of the Bible, which describes visiting the sick as a form of charity.
The first home health care program in the United States was organized in 1796 as the Boston Dispensary.
The first visiting nurse service in the United States was formed in Philadelphia in 1886.
Lillian Wald and Mary Brewster developed a visiting nurse service for the poor in New York City in 1893 at the Nurses' Settlement House on Henry Street.
In the 1800s and early 1900s, visiting nurse associations were formalized, and public health departments became widespread.
The Social Security Act of 1935 first provided government rather than local charitable funding for selected services such as maternal health, communicable disease, and the training of public health professionals.
When Medicare became effective in 1966, it revolutionized home care by
Changing it to a medical rather than nursing model of practice
Defining and limiting services for which it would reimburse
Changing the payment source and even changing the reason home care was provided
What is the benefit of a medical home health care model versus a nursing model?
Describe how the payment source has changed and the reason for home health care.
Diagnosis-Related Groups (DRGs)
Congress enacted this prospective payment system in 1983 as a part of the Tax Equity and Fiscal Responsibility Act for hospitals receiving Medicare reimbursement.
Based on major diagnostic categories, a set rate is paid for the hospitalized patient's care rather than the "cost" or charges traditionally billed by institutions.
Why did Congress pass this Act?
Give an example of how this changed billing.
Diagnosis-Related Groups (DRGs) (continued)
The net effect of the change was a major shift of patients out of the hospital into their homes, extended-care facilities, or skilled nursing facilities.
This created a challenge in terms of volumes of patients seen, necessity of more skilled nursing care over intensive times, and the evolution of highly technical procedures in the home.

Type of Home care agencies

Agencies may have to comply with federal, state, and local laws and regulations via the following:
Licensure by the state
Certification by the state certifying body designated by the federal government
Certificate of need granted by some state according to rules and formulas devised by state regulators
Accreditation by an outside agency that evaluates how well the agency meets certain standards set by the accrediting organization
Agencies Classified According to
Tax status: For profit or not for profit
Location: Freestanding or institution-based
Governance: Private or public
Seven Types of Home Care Agencies
Voluntary
Official
Combination
Hospital
Proprietary
Private not-for-profit
Other

Change in home health care

The Joint Commission (TJC) is looking for agencies to establish ethics committees to handle issues that arise in the home.
Psychiatric nurse clinicians are being reimbursed by Medicare for home visits.
Social workers are taking a more active role in home health care.
More home health agencies are employing nurse pain specialists to assess and manage pain control in the home.

Most agencies are obtaining a separate Medicare certification to provide hospice care.
Pet care programs are emerging to reduce stress for the home health patient who is too ill to care for his or her pet.
Electronic home visits may be evolving.
One of the most rapidly growing segments in home health is home infusion therapy.
Figure 37-1

Service components

Physical Therapy
Services must be provided by a qualified and licensed physical therapist.
A physical therapist's assistant may deliver limited services under the supervision of the licensed therapist.
The goals of treatment must be restorative for Medicare reimbursement but may be maintenance or preventive for other payer sources.
Speech-Language Therapy
Speech services must be provided by a master's-prepared clinician who has been certified by the American Speech and Hearing Association.
Therapy goals include minimizing communication disorders and their physical, emotional, and social impact.
Independent functioning and maximum rehabilitation of speech and language abilities are primary treatment goals.
Occupational Therapy
Services deal with life's practical tasks.
The therapist will choose and teach therapeutic activities designed to restore functional levels.
Services include
Techniques to increase independence
Design, fabrication, and fitting of orthotic or self-help devices
Assessment for vocational training
Medical Social Services
Services are provided by social workers prepared at the master's level.
Focus is on the emotional and social aspects of illness.
The care plan includes education, counseling, payment source identification, and referrals.
Homemaker-Home Health Aide
The aide provides the basic support services that can enable an elderly individual, disabled adult, or dependent child to remain at home.
Most aid services fall into one of three categories
Personal care
Physical assistance
Household chores

The typical home health process

Referral
Entry point into the home health care system
Can come from the patient, family, social service agency, hospital, physician, or another agency
Admission
The initial evaluation and admission visits are made by an RN within 24 to 48 hours of the referral.
The evaluation and admission process generally includes at least the following:
Complete patient evaluation
Environmental assessment
Identification of primary functional impairments
Assessment of the family or significant other support system
Determination of knowledge and adherence to treatments and medications
Determination of desire for care and services
Involvement of the patient and family in the development of the plan of care and goals
Notification to the patient of rights as a patient, along with costs, payment sources, and billing practices
Explanation of the patient's right to self-determination
Provision of initial nursing interventions
Care Plan
The physician must be contacted for specific orders before delivery of care.
A treatment plan is drafted cooperatively with the physician.
The plan describes the current physical status of he patient, medications, treatments, the disciplines needed to provide care, the frequency and duration of services, the goals/outcomes, and the time frame for implementation.
It must be signed by the physician and serves as the traditional physical orders.
Visits
Visits for interventions by ordered disciplines are made to meet the patient-centered goals and progress toward identified outcomes.
Patients may be visited as infrequently as once a month to several times a day; several visits per week is typical.
Documentation
Concise and complete documentation is essential.
It may be hand-written, dictated, or entered into a computer.
Many agencies are beginning to use various problem classification schemes linked with nursing diagnoses, specific interventions, and defined patient outcomes.
It provides an accurate picture of the type and quality of care and reflects the effectiveness of the plan of care and progress toward goals and outcomes or the reason for lack of progress.
Discharge Planning
Planning begins with admission.
When patient goals or other specific criteria are met, the discharge occurs.
The purpose of discharge planning is to promote continuity of care in the patient's home.
Quality Assurance Assessment/Improvement
This provides documentation for outside organizations and for internal measures of improvements and refinements of policies and procedures.
Three major elements
Structural criteria
Process criteria
Outcome criteria
Quality assessment plans reflect standards, objectives, and measurable outcomes and include plans for remediation or improvement as an integral part of the process.

Reimbursement sources

Medicare
This federal program requires agencies to be certified as meeting the federal conditions of participation, which set forth specific requirements for organization, staffing, training, types of services covered, and agency evaluation.
Beneficiaries of services must be 65 or older, disabled, or have end-stage renal disease.
Must be under the care of a licensed physician, homebound, and in need of skilled nursing therapy services
Medicaid
This pays for home care services to indigent and low-income people of all ages.
It is administered by the state but is both state and federally subsidized.
Services vary from state to state, but most include the basic services covered by Medicare plus expansion of aide and personal care services.
Third Party
Limited home care services are paid for.
Coverage, requirements, and payment rates vary.
Reimbursement is often tied to posthospitalization recoveries.
A case manager will determine and arrange for a mix of home care, therapy services, counseling, supplies, and equipment for a patient.
Private Pay
Individuals may also pay directly for home health services. Charges may be the standard full charge or may be scaled down based on ability of the patient to pay.
Other Sources
Health maintenance organizations (HMOs) and preferred provider organizations (PPOs) have negotiated contracts with home health agencies to provide services to their patients.
Both are prepaid health plans operated independently or through employer groups.

Cultural considerations

Nurses encounter great diversity in a variety of cultural interactions.
Culture is present in the lives of patients, families, and health care providers and is especially apparent in the home environment.
Nurses need to anticipate potential cultural problems and identify their own and other's values.
Cultural health practices may be incorporated into traditional medical care in the home environment, provided it does not conflict with the prescribed treatment.

Nursing process and summary

Nursing Diagnoses
Interrupted family process
Impaired parenting
Anxiety
Caregiver role strain
Impaired physical mobility
Imbalanced nutrition, less than body requirements
Disturbed thought processes
Ineffective airway clearance
Risk for impaired skin integrity
Family coping, compromised
Family coping, disabled
Coping, ineffective
Ineffective management of therapeutic regimen
Knowledge, deficient
Risk for caregiver role strain
Risk for injury
OASIS: Outcome and Assessment Information Set
http://ww.oasisanswers.com/about-oasis.htm
Summary
Current trends support the growth of home care as an economical, humane, preferred health delivery system for many types of care.
Home care provides needed assessment and evaluation of chronic illnesses to prevent acute episodes.
Aides and homemakers can provide necessary support in activities of daily living to enable the patient to remain in the home.
Skilled nursing and therapy offer rehabilitation and prevention of deterioration, as well as methods to cope with physical changes.

Department of health and human services (DHHS)

Legitimate mandates are followed
Policies are carried out
Funds appropriately disseminated
Block grant funding: Large sum of money granted by the federal government to states for general use they have identified. (Education, health, Urban development)
Agencies within the Department Of Health
HRSA
IHS
CDC
NIH
FDA
SAMHSA
ATSDR
AHRQ

Public health nurse: plans and implements

Number of Children in US 2015
All Children 73.6 million
0-5 years 24.0 million
6-11 years 24.7 million
12-17 years 25.0 million
(Child stats.gov (2014). Retrieved from http://www.childstats.gov/AMERICASCHILDREN/tables/pop1.asp)
National Association of School Nurses
Http://www.nasn.org/Home
https://www.nasn.org/ToolsResources/Immunizations/VoicesofMeningitis

Back to School Check List (NASN,2015)
http://www.nasn.org/AboutNASN/MediaRoom/NewsReleaseView/tabid/765/ArticleId/859/NASN-Provides-Back-to-School-Checklist-for-Families-and-School-Nurses-Better-Health-Better-Learning

School nurse responsibilities

Statistics
Ideal ratio: 1 nurse to every 750 students or less (PSEA, 2010).
Average ratio: 1 school nurse to every 1500 students
School nurses have a positive effect on decreasing absenteeism and increasing graduation rates
Not Just Handing Out Bandaids!
Primarily responsible for promotion and maintenance of health and prevention of illness in school-aged children and school personnel in an educational setting
Identifies health-related barriers to learning
Advocates for students, their families, and the school community at large

Main function of school nurse practice

Roles - Clinician (care provider), change agent, educator, manager, and advocate
Integrate health services - coordinating the interdisciplinary team effort (counseling, nutrition, physical education)
Provide health education - teaching of health concepts, developing health curriculum, and utilizing resources
Protect the healthful school environment

Programs and Services

Preventive - Immunizations, Screenings (TB testing, vision, hearing, dental, scoliosis), Hygiene, Nutrition and Exercise Programs
Education - Family planning, Infectious disease (STD, HIV), Substance abuse (alcohol, tobacco), Illness/Injury Prevention (MVI, fire, poisoning),
Social Services - Child protective services (abuse and neglect), Counseling, Crisis prevention, Dental (fluoride rinses and sealants)

Federal mandates in school health

Individuals with Disabilities Education Act (IDEA) in 1991- requires that students with disabilities have an IEP(Individual Education Plan) and least restrictive environment possible with related nursing services
Section 504 of the Rehabilitation act of 1973 requires accommodations for persons with disabilities to participate in normal school activities
Nurses are involved because of a health issue
No Child Left Behind (NCLB) in 2001 - mandates educational opportunities for all (including cognitively impaired) and uses annual yearly progress as a basis for funding
A child with special needs to fully participate with reasonable accommodations

Least restrictive environment

"In General. To the maximum extent appropriate, children with disabilities, including children in public or private institutions or other care facilities, are educated with children who are not disabled, and special classes, separate schooling, or other removal of children with disabilities from the regular educational environment occurs only when the nature or severity of the disability of a child is such that education in regular classes with the use of supplementary aids and services cannot be achieved satisfactorily" 20 U.S.C § 1412(a)(5)(A).
What is the educational benefit of a general education classroom to the child;
What is the non-academic benefits (social, emotional, etc.) of a general education classroom to the child;
What is the effect on the teacher and other students; and
What is the cost of mainstreaming the child

5 most common chronic conditions seen in school age children

Asthma
Diabetes
Seizures
Sever food allergies
Attention deficit/behavioral disorders
Helping to Administer to the Needs of Diabetic Children in School
https://www.pathlms.com/nasn/courses/915

Screening: opportunities for teaching

Vision
Hearing
Height
Weight
Scoliosis
Early markers for type 2 diabetes
Healthy people 20/20 - relationship that affect the students

Healthy screening and education

Oral and dental health
Proper nutrition and exercise
Obesity
Undernutrition
Eating disorders

Immunizations

Have decreased
Measles (rubeola)
Rubella (German measles)
Pertussis
Infectious parotitis (mumps)
Varicella (Chickenpox)
Herd immunity is broken down due to people were not immunizing their children so its herd infections!

Legal issues in school nursing

Documentation
Student health records
Delegation
School staff and regulations
Supervision and Accountability
Funding Issues in School Health
Violence and Terrorism in US Schools
Lower school crime rate, improve disaster preparedness

Healthy people 202 for school

Common problems for school age and adolescents
Physical activity
Obesity
Tobacco use
Substance use
Mental health
Injury and violence
Environmental quality
Immunizations
Access to care

Major problems of children

Economic - Increased risks of poor health, lower standardized test scores, failure in school, out-of-wedlock births, violent crime victimization, and end up as poor adults
Accident/Injury - motor vehicle injury is the leading cause, followed by firearm and drowning deaths
Communicable diseases - primarily respiratory illness, followed by infectious and parasitic diseases, injuries, and digestive conditions

10 most common communicable diseases

Common Cold
Gastroenteritis
Strep throat
Pink eye
Fifth Disease
Gonorrhea
Hepatitis
Rotavirus
HIV/AIDES

More major problems

Chronic disease - Commonly hay fever, sinusitis, dermatitis, tonsillitis, asthma, diabetes, seizure disorders, and hearing difficulties; also cancer
Behavioral problems and disabilities - have both genetic and environmental causes; ADHD, speech or language impairment, mental retardation, serious emotional disturbances, autism, deaf-blindness, orthopedic problems, traumatic brain injury
Still More Major Problems
Head lice - a common problem, infesting 6 to 12 million children annually
Nutrition - primarily overeating (obesity) and inappropriate food choices (high intake of intake of fats, sweets and sodas)
Dental hygiene - dental caries most common chronic disease; affects over half
Inactivity - related to TV viewing (staying up late and decreased sleep time ), and lack of daily physical activity

Adolescent health problems

Emotional problems - spiritual poverty, boredom, low self-esteem, depression, and lack of motivation
Violence and Substance abuse - unintentional injuries (MVIs) , homicide and suicide are the top three causes of death; increased risk-taking behavior includes gangs, precocious sex, drugs and alcohol and guns
Indiscriminate sexual activity - result in teen pregnancy and STDs, including HIV/AIDS
Nutrition and eating disorders - obesity and associated with body image and control (anorexia nervosa, bulimia, and binge eating)
Acne - affect 79% to 95% of adolescents in westernized societies; greasy foods or chocolate are not the cause

School nurse training

Usually a registered nurse (frequently BSN)
Operates from either the school system or the health department
A specialized role requiring specialized skills in school health assessment and intervention (some states require certification or credentialing)
School nurse practitioners - advanced academic and clinical preparation

History

Lillian Wald
First used the term "Public Health Nursing"
Started the Henry Street Settlement with Mary Brewster
demonstrated that nursing practice could reduce illness-caused absenteeism in schools, thus increasing the number of days and benefits that increased schooling afforded
convinced the New York City Board of Education in 1902 to hire the first school nurse in the USA - Lina Rogers

Predict the Differences

Home health care
Home health nursing
Hospice and palliative care
How'd You Do?
Home health care
Focus is on the three levels of prevention.
Home health nursing
Focus is on empowerment for highest possible levels of function and health.
Hospice and palliative care
Focus is on optimizing quality of life for those experiencing life-limiting, progressive illness.

Evolution of Home Health and Hospice

Initial programs (19th century)
Evolved into visiting nurse associations
Henry Street Settlement House
Medicare and Medicaid (1965)
Home health services included
Hospice care introduction (1970s)
Florence Wald
Balanced Budget Act (1997)
Closure of over 30% of Medicare-certified home health agencies
Evolution of Home Health and Hospice (Cont.)
Cleveland Clinic in 1987
First comprehensive, integrated palliative care program
Center to Advance Palliative Care (1999)
Robert Wood Johnson Foundation
Medicaid reimbursement for hospice (1980)
Medicare reimbursement for hospice (1983)

Description of Practice Models

Population-focused home care
Transitional care
Home-based primary care
Home health
Hospice/palliative care

Population-Focused Home Care

Evidence-based and data-driven approach
Structured approaches to regular visits with the following:
Assessment protocols
Focused health education
Counseling
Health-related support and coaching
Examples
Patients with psychiatric illnesses
Pharmacist home visit to older adults with atrial fibrillation and heart failure
Elderly diabetic patients living alone
Nurse-family partnership
Program of All-Inclusive Care for the Elderly (PACE)

Transitional Care

Ensures coordination and continuity of health care as patients transfer between different locations and different levels of care in the same location
Low-intensity interventions
High-intensity interventions
Transitional care model
Advanced practice nurses
In-hospital visits/discharge planning
Home visit follow-ups, primary care office visits
Telephone follow-up for 1 to 3 months after discharge

Home-Based Primary Care

Offers patients an alternative to receiving services in a primary care clinic, community center, or physician's office
Serves patients with functional or other health problems that make the trip from their homes to other care sites very difficult
Examples
Veterans Health Administration Hospital-Based Home Care Program
Medical home (Centralized and accessible)

Home Health

Provide care at home
Help patients and their families achieve improved health and independence in a safe environment
Medicare-certified
Recipients have diverse needs.
Most common diagnosis is circulatory disease, followed by neoplasms and endocrine diseases (especially diabetes)
Skilled nursing services
National and state regulations in place

Types of Home Health Agencies

Home health agencies can be divided into five general categories:
Official/public: approximately 13% of total home health agencies
Private and voluntary: approximately 12% of total home health agencies
Combination: approximately 0.5% of total home health agencies
Hospital based: approximately 19% of total home health agencies
Proprietary: approximately 56% of total home health agencies

Hospice and Palliative Care

Four types of care:
Routine home care with intermittent visits
Continuous home care when condition is acute and death is near
General inpatient/hospital care for symptom relief
Respite care in nursing home of no more than 5 days at a time to relieve family members
Four categories of hospice providers:
Home health agencies
Hospital-based facilities
Skilled nursing facilities
Freestanding facilities
Four foci of hospice:
1. Attention to body, mind, and spirit
2. Death is not a taboo topic.
3. Health care technology used with discretion
4. Clients have a right to truthful discussion and participation in treatment decisions.
Interprofessional hospice team
Nurses
Physicians
Social workers
Therapists/counselors
Chaplains
Aides
Pharmacists
Volunteers

Home Care of Dying Children

Nurse's role
Understand the child's level of physical, cognitive, psychosocial, and spiritual development.
Understand family dynamics, cultural heritage, and spiritual beliefs.
Provide appropriate pain management.
Assist child and family to communicate.
Advocate for their needs.
Provide case management and continuity.
Recommend bereavement programs.

Scope and Standards

Quad Council's core public health nursing (PHN) competencies
Analytic/assessment skills
Policy development/program planning skills
Communication skills
Basic public health sciences skills
Financial planning and management skills
Leadership and systems thinking skills
Students and new graduates cannot be expected to have developed all of these skills when they begin home health or hospice practice. However, as nurses proceed in their career development and gain valuable work experience, they will progress along the novice to expert continuum.
Quad Council's eight domains of practice
Nursing process
Assessment
Diagnosis
Outcomes identification
Planning
Implementation
Evaluation
Standards of care and standards of professional performance
Quality of care
Performance appraisal
Critical thinking skill
Education
Collegiality
Ethics
Collaboration
Research
Resource use
Omaha System
Initially developed to operationalize the nursing process and provide a practical, easily understood, computer-compatible guide for daily use in community settings
Nursing practice
Documentation
Information management
Transformation data into meaningful decision-making tools
Electronic health records (EHRs)

Quick recall 2

Which of the following represents a core competency of the Quad Council's domains of public health nursing?
A. Ethics
B. Collegiality
C. Outcomes identification
D. Leadership and systems thinking
Answer is Answer D
How'd You Do?
Quad Council's core PHN competencies include the following:
Ethics
Collegiality
Outcomes identification
Leadership and systems thinking
Tip: Competencies are about PHN skills in particular—not about either the nursing process steps or basic standards of care.
Ethics is a standard of care.
Collegiality is a standard of care.
Outcomes identification is a step in the nursing process.
Leadership and systems thinking is one of the QC's core PHN competencies.

Omaha system conceptual model

As depicted in Figure 41-3, the Omaha System conceptual model is based on the dynamic, interactive nature of the nursing or problem-solving process, the practitioner-patient relationship, and concepts of diagnostic reasoning, clinical judgment, and quality improvement. The patient as an individual, a family, or a community appears at the center of the model; this location suggests the many ways the Omaha System can be used and the essential partnership between patients and practitioners.

Omaha system goals

Use by all team members
Develop a structured, comprehensive system understood by differing disciplines.
Foster collaborative practice.
Guide practice decisions.
Sort and document client data uniformly.
Frame multidisciplinary information.

Omaha Problem Classification Scheme

Four domains:
Environmental
Psychosocial
Physiological
Health-related behaviors

Omaha System Intervention Scheme

Four broad intervention categories
Teaching, guidance, and counseling
Treatments and procedures
Case management
Surveillance
Targets or objects of action (75)
Client-specific information

Omaha problem classification scheme

Omaha system problem rating scale for problem-specific client outcomes
Three five-point Likert-type scales for measuring severity for the following concepts:
Knowledge
Behavior
Status

Quick recall 3

Which of the following represents one of the four domains of the Omaha problem classification scheme?
A. Ethics
B. Knowledge
C. Surveillance
D. Health-related behaviors
Answer is D

How'd You Do?
The four domains of the Omaha problem classification scheme constitute a comprehensive, orderly, taxonomy designed to identify diverse clients' health-related concerns, which include the following:
Ethics
Knowledge
Surveillance
Health-related behaviors
Ethics is a standard of care.
Knowledge is a measurable problem-specific client outcome.
Surveillance is an intervention category.
Health-related behaviors (e.g., nutrition) is one of four domains that identifies diverse clients' health-related concerns. The other three are (1) environmental domain, (2) psychosocial domain, and (3) physiological domain.

Practice Guidelines

Steps of a home visit
Clinical examples from practice
Martha P.
Mr. Jones
Arizona childcare health consultant program
Practice Linkages
Goal setting
Provides evaluation criteria
Increases continuity of care
Increases potential for improved outcome
Practice Linkages (Cont.)
Outcome and Assessment Information Set (OASIS)
Designed to demonstrate improved, cost-effective client outcomes

Two key OASIS target areas

Medication management
Infection prevention

Two-Stage CMS OBQI Reporting Framework

The first stage, outcome analysis, enables an agency to compare its performance to a national sample, note factors that may affect outcomes, and identify final outcomes that show improvement in or stabilization of a client's condition.
The second stage, known as outcome enhancement, enables the agency to select specific client outcomes and determine strategies to improve care. Reports include agency-client-related characteristics (case mix), potentially avoidable events (adverse event outcomes), and end-result and utilization outcomes.

Accountability and Quality Management

Evidence-based quality/performance improvement
Emphasis on documentation
Outcome-based quality improvement
Benchmarking: comparing agency data and trends to a national sample
Accreditation
Professional Development and Collaboration
Education, certification, and roles
Bachelor's versus master's degree roles
Hospice and Palliative Nurses Association
Interprofessional collaboration
Physical therapists
Occupational therapists
Social workers
Home health aids
Legal, Ethical, and Financial Issues
Medicare fraud and abuse
Living will
Power of attorney for health care
Do not resuscitate (DNR) documents
Local, state, and federal regulations
Patient advocacy
Malpractice
Complex reimbursement regulations
Nurses who work in home health, palliative care, and hospice are involved with financial aspects of care to a greater extent than most other nurses. Nurses and their social work colleagues must be well informed about services that are covered by Medicare and other funding sources, and they must recognize how tenuous those funding sources are.

Trends and Opportunities

National health objectives
Healthy People 2020
Organizational and professional resources
Home health organizations
Journals
Hospice and palliative care organizations
Technology, informatics, and telehealth
American Nurses Association (ANA) steps to manage the impact
1. Recognized standardized terminology
2. Planned interoperability
3. Identification of "meaningful use"
Advances in technology, informatics, and telehealth should not be viewed as replacements for nurses and team members but as tools to improve the quality of their practice. The tools are evolving rapidly, influencing the practice of home health nurses, and transforming home health operations.
Issues in Public Health Nursing: Home Health Nursing
Aimee says, "I wouldn't trade my job for anything. Sure, there are a lot of requirements, and a lot of competencies to strive for, but the longer I'm on the job, the more I value the opportunity to improve the lives of both patients and caregivers, making end-of-life challenges as rewarding and stress-free for them as possible. I can't think of anything I'd rather be doing."

Definition and Scope

Occupational and environmental health nursing:
Specialty practice that focuses on the promotion, prevention, and restoration of health within the context of a safe and healthy environment
American Association of Occupational Health Nurses (AAOHN)
AAOHN code of ethics

Issues in Public Health Nursing: The Nurse in Occupational Health

Arthur works as an occupational health nursing consultant at an on-site health and safety team for a string of warehouses for a large online supply company.
"Employees are timed in how fast they fill, pack, and ship orders," he says.
Other members of Arthur's team include workers' reps, an ergonomist, an industrial hygienist, and a safety professional. Arthur also collaborates with an occupational physician who provides consultation and accepts referrals when medical intervention is needed.

History and Evolution

1888: industrial nursing started
Employee health service grew rapidly (1900s)
Provision of worksite health services led to a more productive workforce
Occupational Safety and Health Act of 1970
Created OSHA and NIOSH
Office of Occupational Health Nursing (1993)
AAOHN published first set of competencies in occupational health nursing (1999)

Roles and Professionalism

Role has extended beyond—
Emergency treatment and prevention of illness and injury
To include the following:
Promotion and maintenance of health
Overall risk management
Care for environment
Efforts to reduce health-related costs in business
Occupational health nurse positions
Nurse practitioners
Clinical nurse specialists
Managers
Supervisors
Consultants
Educators
Researchers
Academic education
Master's and doctoral

Workers as a Population Aggregate

Dramatic population increase
Dramatic increase in workers over 55 years of age
More than 91% work outside the home for some portion of their lives.
Most prominent U.S. industries
Service industries
Agriculture
Construction
High-technology
Manufacturing
Fastest growing occupations: 60% in areas related to health care

Characteristics of the Workforce

Shift from manufacturing to service or technology
Longer hours, compressed workweeks, shift work, reduced job security, part-time and temporary work
New chemicals, materials, processes, and equipment
Changing workforce
More women
More older people
More chronic illness

Characteristics of Work

Shift in types of jobs
From agrarian to manufacturing to technological
New occupational hazards
Complex chemicals
Nanotechnology
Nonergonomic workstation design
Work organization issues
Job stress
Burnout
Exhaustion
Global economy
New health and safety challenges
Occupational Injuries and Illness

Work-Health Interactions

3.4 work injuries and occupational illnesses per 100 workers (2011)
More than $100 billion in lost wages and lost productivity, administrative expenses, health care, and other costs (2006)
Many work-related health problems go unreported
Occupational Safety and Health Act

Application of the Epidemiologic Model

Host
All employed individuals and groups are at risk of being exposed to occupational hazards.
Agent
Occupational exposures that are classified as biological, chemical, enviromechanical, physical, or psychosocial
Environment
Workplace conditions, such as temperature extremes, crowding, shift work, and inflexible management styles
Organizational and Public Efforts to Promote Worker Health and Safety
On-site occupational health and safety programs
Unless they have OSHA-regulated exposures, businesses are not required to provide occupational health and safety services that meet any specified standards.

Nursing care of working populations

Levels of prevention
Primary: measures designed to promote general health; providing protective barriers against agents
Secondary: early diagnosis and prompt treatment to prevent sequelae and limit disability
Tertiary: rehabilitation
Worker assessment
Occupational health history
Opportunity to teach preventive measures
Workplace assessment
Worksite walk-though or survey

Quick recall 4

Which of the following actions that Arthur has taken over the past 6 months represents secondary prevention?
A. Routinely screening patients for risk of stress levels and chronic motion injury and testing the workplace environment for hazards
B. Advising architects on how to create a safer new warehouse and better tactical system
C. Creating a rehabilitation program to help injured workers get back to work in newer, safer surroundings
D. Final workplace inspection before opening a newly completed facility
Answer is A
Get That?
Secondary prevention involves both (a) screening for early diagnosis and (b) providing adequate treatment to prevent sequelae and limit disability. Later, when defect and disability have been resolved, tertiary prevention may be accomplished by rehabilitation. By contrast, primary prevention involves strategies that offer pre-pathogenesis protection, like planning for adequate barriers before exposing workers from the outset.

Issues in Public Health Nursing: The Nurse in Occupational Health

The company Arthur serves is concerned about the level of injuries in its first two warehouses over the past year. Now as the company is building its third warehouse in the region, the organization has asked Arthur to work with the management to plan the new structure with prevention in mind.
"It doesn't happen a lot, at least for me," Arthur says. "I get a lot more chances to do secondary and tertiary prevention than I do primary prevention. But thanks to better education, I think more companies are getting the message: Primary prevention saves having to do the rest.

Healthy People 2020
Occupational safety and health objectives were identified to do the following:

Promote good health and well-being among workers.
Eliminate or reduce harmful environmental elements that cause death, injury, disease, or disability.
Promote the minimization of personal damage from existing occupationally related illnesses.
Legislation
Mine Safety and Health Act of 1968
Occupational Safety and Health Act (OSHA)
Hazards Communication Standard
National Institute for Occupation Safety and Health (NIOSH)
National Occupational Research Agenda (NORA)
Workers' compensation acts
Vary by state

Historical Perspectives

Historically, health researchers focused on issues predominantly oriented toward men.
Early 1900s: Women's health focused on reproduction and women's roles as mothers.
1920s: Women's health expanded to address family planning and reproductive health (beginning of birth control movement).
1980s: U.S. Public Health Service (PHS) Task Force on Women's Health Issues
1990: Society for Women's Research
Health Policy and Legislation
Older Americans Act of 1965
Americans with Disabilities Act of 1990
Family Medical Leave Act of 1993
Personal Responsibility and Work Opportunity Reconciliation Act of 1996
"Welfare reform"
Temporary Assistance for Needy Families (TANF)
Patient Protection and Affordable Care Act (2010)
• Health policy is action taken by public and private agencies to promote health. It is a reflection of the values held in society and can greatly influence the health of the citizens overall.
• Legislation consists of laws that regulate health care and promote health. Nursing practice and the care provided are impacted by policy and legislation.
Nurses must understand how policy and legislation, along with other system factors such as social, cultural, and economic forces, can be incorporated into planning care for clients and use their skills as collaborators and communicators to improve health po

Ethical and Legal Issues, and Legislation for Older Adults

Abuse
Neglect
Financial exploitation
Patient Self-Determination Act of 1991
Advance medical directives
Living will
Durable medical power of attorney
Do-not-resuscitate (DNR) order
Environmental Impact
Men and women are often exposed to differing environmental factors because of upbringing, employment, cultural or tradition variations
Men and women may respond differently to environmental factors.
Centers for Disease Control and Prevention's (CDC's) Environmental Hazards and Effects Program (EHEP)
Women and girsl are affeced more by air population
Health Status Indicators
Mortality
Life expectancy
Mortality rates
Morbidity
Increasing prevalence of chronic diseases and other conditions associated with aging
High prevalence of adults with risk factors
Health status indicators are the quantitative or qualitative measures used to describe the level of well-being or illness present in a defined population or to describe related attributes or risk factors. They can be represented in the form of rates, such as mortality and morbidity, or proportions, such as percentages of a given population that receive immunizations.

Adult Health Concerns

Chronic disease
Cardiovascular disease
Hypertension
Stroke
Diabetes
Mental health
Cancer
Sexually transmitted diseases (STDs)/HIV/AIDS
Weight control
Chronic Disease
Most common
Heart disease
Diabetes
Stroke
Cancer
Arthritis
Chronic disease is leading cause of preventable deaths, disability, and decreased quality of life
The costs of chronic disease accounted for more than 75% of the nation's $1.4 trillion medical care spending in 2007.

Quick recall 5

Which is one of the most common chronic diseases in the United States?
Chronic obstructive pulmonary disease (COPD)
Asthma
Stroke
Crohn's disease
Ansewr is C
How'd You Do?
Five most common chronic diseases
Heart disease
Diabetes
Stroke
Cancer
Arthritis

Wagner's Chronic Care Model

Essential elements of high-quality chronic disease care
Community
Health system
Self-management support
Delivery system design
Decision support
Clinical information systems
The chronic care model (CCM) identifies the essential elements of a health care system that encourage high-quality chronic disease care. These elements are the community, the health system, self-management support, delivery system design, decision support, and clinical information systems.

Cardiovascular Disease (CVD)

Affects 83.6 million adults
Leading cause of U.S. deaths for the following groups:
African Americans
American Indians
Alaska Natives
Hispanics
Whites
23 Healthy People 2020 objectives focus on CVD
Gaps in knowledge and awareness for heart disease, particularly in women
Hypertension (HTN)
Affects one in three U.S. adults
Uncontrolled HTN leads to the following:
Heart attack
Stroke
Kidney damage and the like
18% are unaware they have it
Racial, ethnic, and socioeconomic differences

Stroke

U.S. occurrence: decreased since the 1950s
2002: 7 million
2010: 6.8 million
Women more likely to die from stroke
Live longer than men
Stroke events increase with age
Healthy People 2020 objective
Reduce stroke deaths to 48 in 100,000

Diabetes (DM)

19.7 million people with DM in 2010
1 in 12 to 13 adults has DM
Costs the United States $174 billion each year
Many complications associated with DM
Heart disease, stroke, hypertension, retinopathy, kidney disease, neuropathy, amputations, and dental disease
At least 18 Healthy People 2020 goals related to DM
The many complications associated with diabetes include heart disease, stroke, hypertension, retinopathy, kidney disease, neuropathies, amputations, and dental disease.

Mental Illness

Common form of disability
2012 statistics (U.S.)
43.7 million adults with mental illness
9.6 million categorized as serious
Gender differences
Men have higher suicide rate.
Women have higher incidence of depression and anxiety.
Community education needs
Dispel stereotypes and fears.
Broadcast positive attributes of individuals.
Mental illness is generally viewed by society in a negative manner. This social stigma or mark of shame leads to guilt, low self-esteem, social isolation, and ultimately to poorer health.

Cancer

Second leading cause of U.S. deaths
Overall costs of cancer in 2009
$216.6 billion
Needed to reduce the burden of cancer
Early screening and detection
Promotion of healthy lifestyles
Expansion of access to services
Improvement in cancer treatments

STDs/HIV/AIDS

19 million new STD infections per year
Almost half occur in people 15 to 24 years of age.
Many cases go undiagnosed.
50,000 new cases of HIV/AIDS
African Americans: 44%
Hispanics: 21%
Healthy People 2020
Promote responsible sexual behaviors, strengthen community capacity, and increase access to quality services to prevent STDs and their complications.

Weight Control

Overweight and obesity costs
2009: $147 billion, or 10% of U.S. health care cost
Body mass index (BMI)
2008 Physical Activity Guidelines
Anorexia nervosa
Bulimia
Women's Health Concerns
Reproductive health
Preconceptual counseling
Gestational diabetes
Menopause
Breast cancer
Osteoporosis
Men's Health Concerns
Lack of health screenings
Dangerous employment
Cancers unique to men
Prostate cancer
Testicular cancer
Depression
Erectile dysfunction
Large numbers of men do not receive the health screenings intended to prevent and identify disease.

Health Disparities

Adults of color
Incarcerated adults
Lesbian/gay/bisexual adults
Adults with physical and mental disabilities
Impoverished adults
Frail elderly

Community-Based Models for Care of Adults

Nursing roles
Direct care
Providing self-care information
Contributing to supervision of paraprofessionals
Interdisciplinary collaboration on care decisions
Assessing for and developing community resources
Referral to best community resources
Community care settings
Patient-centered medical homes
Senior centers
Adult day health
Home health, palliative care, and hospice
Assisted living
Long-term care and rehabilitation

Chronic Disease

The Leading Causes of Death and Disability in the United States.
Chronic diseases and conditions—such as heart disease, stroke, cancer, type 2 diabetes, obesity, and arthritis—are among the most common, costly, and preventable of all health problems. (CDD, 2016)

One in four Americans has multiple chronic conditions, those that last a year or more and require ongoing medical attention or that limit activities of daily living. That number rises to three in four Americans aged 65 and older.

Underlying causes

This high prevalence has several underlying causes:
The rapidly growing population of older adults
The increasing life expectancy associated with advances in public health and clinical medicine
The high prevalence of some risk factors, such as tobacco use and physical inactivity.

As a person's number of chronic conditions increases, his or her risk for dying prematurely, being hospitalized, and even receiving conflicting advice from health care providers increases. People with multiple chronic conditions also are at greater risk of poor day-to-day functioning.

Having multiple chronic conditions is also associated with substantial health care costs. Approximately 71% of the total health care spending in the United States is associated with care for the Americans with more than one chronic condition. Among Medicare fee-for-service beneficiaries, people with multiple chronic conditions account for 93% of total Medicare spending. People with multiple chronic conditions face substantial out-of-pocket costs of their care, including higher costs for prescription drugs.
(CDC, 2015)
National Center for Chronic Disease Prevention and Health Promotion

http://www.cdc.gov/chronicdisease/resources/publications/aag/pdf/2015/nccdphp-aag.pdf

Chronic disease Prevention and Health Promotion

Conduct surveillance of health care preventive services, such as cancer screening
The "ABCS" of heart disease and stroke prevention (Aspirin use, Blood pressure and Cholesterol control, and Smoking cessation)
Measures of diabetes control (e.g., hemoglobin A1C) and obesity
(e.g., body mass index)

Common Risk Factors

High blood pressure.
Tobacco use and exposure to secondhand smoke.
Obesity (high body mass index).
Physical inactivity.
Excessive alcohol use.
Diets low in fruits and vegetables.
Diets high in sodium and saturated fats.

Chronic Disease Prevention

Four Domains
1.Epidemiology and surveillance—to monitor trends and track progress.
2.Environmental approaches—to promote health and support healthy behaviors.
3.Health care system interventions—to improve the effective delivery and use of clinical and other high-value preventive services.
4. Community programs linked to clinical services—to improve and sustain management of chronic conditions.

Diabetes

A fasting blood sugar level from 100 to 125 mg/dL (5.6 to 6.9 mmol/L) is considered prediabetes.
If it's 126 mg/dL (7 mmol/L) or higher on two separate tests, you have diabetes.
Oral glucose tolerance test. For this test, you fast overnight, and the fasting blood sugar level is measured.

http://www.mayoclinic.org/diseases-conditions/diabetes/basics/tests-diagnosis/con-20033091
American Diabetes Association
http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/hypoglycemia-low-blood.html
Diabetes Management
http://www.atitesting.com/ati_next_gen/skillsmodules/content/diabetes-management/accepted-practice/injectable_diabetic_medications.html

Left-sided heart failure

The heart's pumping action moves oxygen-rich blood as it travels from the lungs to the left atrium, then on to the left ventricle, which pumps it to the rest of the body. The left ventricle supplies most of the heart's pumping power, so it's larger than the other chambers and essential for normal function. In left-sided or left ventricular (LV) heart failure, the left side of the heart must work harder to pump the same amount of blood.
There are two types of left-sided heart failure. Drug treatments are different for the two types.
Systolic failure: The left ventricle loses its ability to contract normally. The heart can't pump with enough force to push enough blood into circulation.
Diastolic failure (also called diastolic dysfunction): The left ventricle loses its ability to relax normally (because the muscle has become stiff). The heart can't properly fill with blood during the resting period between each beat.

Right sided heart failure

The heart's pumping action moves "used" blood that returns to the heart through the veins through the right atrium into the right ventricle. The right ventricle then pumps the blood back out of the heart into the lungs to be replenished with oxygen.

Right-Sided or Ventricular Heart Failure
Right-sided or right ventricular (RV) heart failure usually occurs as a result of left-sided failure. When the left ventricle fails, increased fluid pressure is, in effect, transferred back through the lungs, ultimately damaging the heart's right side. When the right side loses pumping power, blood backs up in the body's veins. This usually causes swelling or congestion in the legs, ankles and swelling within the abdomen such as the GI tract and liver (causing ascites).

Congestive Heart Failure

As blood flow out of the heart slows, blood returning to the heart through the veins backs up, causing congestion in the body's tissues. Often edema results. Most often there's swelling in the legs and ankles, but it can happen in other parts of the body, too.
CHF
As blood flow out of the heart slows, blood returning to the heart through the veins backs up, causing congestion in the body's tissues. Often edema results. Most often there's edema in the legs and ankles, but it can happen in other parts of the body, too.
CHF
Heart failure also affects the kidneys' ability to dispose of sodium and water. This retained water also increases edema.

Stages of Heart Failure

Stage AAt high risk for HF (heart failure) but without structural heart disease or symptoms of HF
Stage BStructural heart disease but without signs or symptoms of HF
Stage CStructural heart disease with prior or current symptoms of HF
Stage DRefractory HF (heart failure) requiring specialized interventions

Measure to Emphasize with Heart Failure

Daily weight
Restrict sodium to 2000 mgms per day or less
Avoid Alcohol use
Maintain current immunizations to prevent pneumonia
Meds as directed
Follow up visits with health care provider
Quit smoking

Community Defined

"A group of people ...
often living in a defined geographical area,
who may share a common culture, values and norms, and
are arranged in a social structure according to relationships which the community has developed over a period of time.
Members of a community ...
gain their personal and social identity by sharing common beliefs, values and norms which ...
--have been developed by the community in the past and may be modified in the future"
—World Health Organization (WHO), 2004
In most definitions, community includes three factors:
People
Place
Function

Community as Client

Nursing care of the community as client
Community as client
Community health
Community partnerships for assessment
The nurse's role in the community
Their common goal of community health involves an ongoing series of health-promoting changes rather than a fixed state. The most effective means of completing healthy changes in the community is through this same partnership.

Nursing Care of the Community as Client

Nursing focus
The collective or common good of the population instead of on individual health
Highlights the complexity of the change process
Direct nursing care
Can be a part of population-focused community health practice
Zero is the amount of lead in children's bodies
Community as Client
Population-centered practice
Core public health functions
Assessment
Assurance
Policy development

Ethical Concepts Guiding This Perspective

Utilitarianism
Doing the greatest good for the greatest number of people
Distributive justice
Treating people fairly and distributing resources and burdens equitably among the members of a society
Social justice
Ensuring that vulnerable groups are included in equitable distribution of resources

Quick recall 6

Which approach to community health views individuals as having dynamic interactions with social and environmental features of communities?
A. Utilitarianism model
B. Social justice model
C. Socio-ecological model
D. Distributive justice model
Answer is C
Get That?
The socio-ecological model views individuals as having dynamic interactions with social and environmental features of communities (for example, Neuman's health care systems model).
Multilateral organizations are those that receive funding from multiple government and non-government sources. The major organizations include the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), the Pan American Health Organization (PAHO), and the World Bank.
A bilateral organization is a single government agency that provides aid to lesser-developed countries, such as the U.S. Agency for International Development (USAID).
NGOs or PVOs are non-governmental organizations or private voluntary organizations represented by such agencies as Oxfam, Project Hope, the International Red Cross, various professional and trade organizations, Catholic Relief Services (CRS), church-sponsored health care missionaries, and many other private groups.

Community Partnerships for Assessment

Partnerships
Promote community members' investment in the success of efforts to improve the health of their community
Mobilizing for Action through Planning and Partnerships (MAPP)
Nurse-community partnerships
Coalitions
Passive participation
Active participation

The Nurse's Role in the Community

Establish credibility and trust
Frequent insider status
Gatekeepers
Community leaders who create opportunities for nurses to meet diverse community members
Community health workers
Community members from diverse backgrounds who receive training to perform health outreach work

Community Assessment

Why community assessment?
Data sources
Community health assessment models
Most nurses are familiar with the nursing process as it applies to individually focused nursing care. Using it to promote community health makes this same nursing process community focused. The phases of the nursing process that directly involve the community as patient begin at the start of the contract or partnership and include assessing, diagnosing, planning, implementing, and evaluating.
Taking detailed stock of a community
Focuses from the inside and from the outside
Sometimes called community needs assessment
Requires clinical judgment
Requires critical appraisal of multiple types of data
Requires clear knowledge and understanding of the community as client

Why Community Assessment?

To learn more about the following:
Community needs
Community strengths
Locating confirmation data to address a recognized community problem
Public health nurses (PHNs) are ideal assessment leaders
Public health nursing competencies
The public health nursing competencies include eight major domains: analytic and assessment skills, policy development/program planning skills, communication skills, cultural competency skills, community dimensions of practice skills, public health sciences skills, financial management and planning skills, and leadership and systems thinking skills.
Data Sources
Health status indicators
Secondary sources of data
Websites, printed materials
Primary sources of data
Participant observation
Key informants
Focus group
Photovoice
Spatial data
Geographic information systems (GIS)
Using primary data
The basic process to incorporate Photovoice into a community assessment:
1. Train participants: Participants receive training in Photovoice methods, including the topic of interest, basic photography techniques, and ethical and safety issues. Participants may need to learn how to obtain written consent before photographing people, businesses, or other identifiable subjects. Training is especially important when the topic of interest is sensitive or illegal, such as substance abuse.
2. Take photos: Participants take the cameras into their communities and take photographs that reflect the topic. Equipment should be modified to fit the participants. For example, adolescents may be very comfortable with a variety of mobile devices, whereas older adults may prefer simpler cameras with modifications for low vision or manual dexterity (Novek et al, 2012).
3. Display photos: The photos are collected from the participants, and then printed or digitally projected for group participants, and sometimes members of the public, to view them.
4. Discuss photos: Viewing the photos is meant to spark discussions that provide additional information about the topic of interest. These discussions may take place as focus groups with the Photovoice participants. If the photos are displayed in public, the aim may be to raise awareness and to start conversations among diverse stakeholders.
5. Analyze and report results: The information gathered through these discussions, as well as the photos themselves, can be included in the data analysis phase. The photos can also be part of the report to the community about the findings of the community assessment (Catalani & Minkler, 2010).

Community Health Assessment Models

Many existing models
WHO's Healthy Cities initiative
Centers for Disease Control and Prevention's Community Assessment for Public Health Emergency Response (CASPER)
Community Food Security Assessment Toolkit
Neighborhood Environment Walkability Survey (NEWS)

Community as Partner

Based on nursing processes and theories
Emphasizes dynamic nature of community systems as integral to health of residents
Community subsystems
Physical environment
Health and social services
Economy
Transportation and safety
Politics and government
Communication
Education
Recreation

How to Conduct a Community Assessment

Getting started
Windshield survey
Community "place" and "people" identified
The seven "A's"
Data analysis
Nursing diagnosis
Program planning, implementation, and evaluation
Most nurses are familiar with the nursing process as it applies to individually focused nursing care. Using it to promote community health makes this same nursing process community focused. The phases of the nursing process that directly involve the community as patient begin at the start of the contract or partnership and include assessing, diagnosing, planning, implementing, and evaluating.

Getting Started

Identify one model to guide the assessment.
Visit and interact in the community.
Collect data about people, place, and function for a month or more to get a feel for the community.
Use community coalitions and inclusion of stakeholders.

Windshield Survey

A method of simple observation
Provides a quick overview of the community
Provides first step in generating data to identify community trends, stability, and changes
Can observe many dimensions of community life through the windshield, but walking the streets also provides information
Things to observe
Common characteristics of people, neighborhood gathering places, rhythm of community life, housing quality, geographic boundaries

Community "Place" and "People" Identified

Place
Boundaries
Environment
Size
Climate
History
Population
People
Size and density of population
Demographic structure
Educational attainment
Informal and formal groups
Linking structures
Schools, neighborhood associations, civic clubs
Values and beliefs
Churches, synagogues, mosques, political affiliations

The Seven "A's"

Awareness
Access
Availability
Affordability
Acceptability
Appropriateness
Adequacy

Data Analysis

Follow the model you have chosen
Create census and demographic data tables
Organize data related to each system
Tabulate morbidity and mortality data
Identify health assets and challenges
Prioritize

Nursing Diagnosis

Helps clarify the prioritized problems
Acts as an important first step to planning
Clarifies the target population and identifies factors contributing to the identified problem
Standardized classification systems
NANDA
Omaha system

Program Planning, Implementation, and Evaluation

Planning
Analyzing and establishing priorities among health problems identified through nursing diagnosis
Establishing goals and objectives
Identifying activities to accomplish objectives
Implementation
Enacting the plan for improved community health using identified goals and objectives
Evaluation
Measuring the success of the program and determining community satisfaction with outcomes

Historic Overview

Red Cross Rural Nursing Service (1912)
Before this, care of the sick in small communities was provided by informal social support systems.
Problems in rural communities for generations
Maldistribution of health professionals
Poverty
Limited access to services
Ignorance
Social isolation
You need a half hour to increase your chances of survival to get to a health center

Rurality: A Subjective Concept

Increasing urban influence
Differences in rural versus urban less significant now
Rural = multiple definitions
Farm residency versus nonfarm residency
Each town is distinct.
Rural is defined in terms of the geographic location and population density, or it may be described in terms of the distance from (e.g., 20 miles) or the time (e.g., 30 minutes) needed to commute to an urban center.

Current Perspectives

Population characteristics
Health status of rural residents

Population Characteristics: Rural*

More whites
Higher proportion of younger (under 18 years of age) and older residents (over 65 years of age)
More likely to be married
More likely to be widowed
More likely to be poorer
Fewer years of formal education
At risk for being underinsured or uninsured
*This list denotes general trends. There are, of course, regional variations (for instance, some rural counties have a significant minority population).

Health Status of Rural Residents

Perceived health status
Chronic illness
Rural-urban health disparities
Physical limitations
Availability and access of health care
Health professional shortage area (HPSA)
Patterns of health service use
Maternal-infant health
Health of children
Mental health
Health of minorities
Environmental and occupational health risks
Rural adults are more likely than urban adults to have one or more of the following chronic conditions: heart disease, chronic obstructive pulmonary disease, hypertension, arthritis, rheumatism, diabetes, cardiovascular disease, and cancer.

Rural Health Care Delivery Issues and Barriers to Care

Lack of health care providers and services
Great distances to obtain services
Lack of personal transportation
Unavailable public transportation
Lack of telephone services
Unavailable outreach services
Inequitable reimbursement policies for providers
Unpredictable weather or travel conditions
Inability to pay for care/lack of health insurance

Preparing Nurses for Rural Practice Settings

Rural nurses need broad knowledge, including knowledge in these areas:
Health promotion, primary prevention, pediatrics, rehabilitation, obstetrics, medical-surgical care
Planning and implementing community assessments
Understanding the public health risks and needs for emergency preparedness in a particular state
Telehealth: uses a variety of technological solutions to provide preventive, promotive, and curative aspects of health care

Examples of telehealth solutions:

Communicating by e-mail with clients
Ordering medications from a pharmacy
Consulting with other health care providers
Accessing advanced or continuing education offered by a university located some distance from the receiving site
Telecommunication technology could be as simple as nurses in two or more different public health settings consulting over the telephone or via computer video conferencing coordinating local health fairs, or as complex as nurse scholars collaborating with international peers on a community health-focused research project or a medical specialist located at a health science center completing complex robotic surgical technology on a client who is located in another country.

Future Perspectives

Scarce Resources and Comprehensive Health Care Continuum
Healthy People 2020 National Health Objectives Related to Rural Health

Scarce Resources and Comprehensive Care Continuum

Needed in most rural areas
School and parish nurses
Family planning services
Prenatal and postpartum services
Resources for clients with HIV/AIDS and families
Emergency medical services
Resources for families of children with special needs, including those who are physically and mentally challenged
Mental health services
Resources for older adults

Healthy People 2020

CDC's Healthy Communities Initiative
When implementing community-focused health plans that emerge from Healthy People 2020, consideration must always be given to the rural context, such as these:
Sparse population
Geographic remoteness
Scarce resources
Personnel shortages
Physical, emotional, and social isolation
It remains to be seen if a parallel rural compendium will be developed for Healthy People 2020.
Healthy People 2020
These selected objectives pertain to residents of both rural and urban areas:
AHS-3: Increase the proportion of persons with a usual primary care provider.
IVP-13: Reduce motor vehicle crash-related deaths.
MHMD-9: Increase the proportion of adults with mental disorders who receive treatment.
HDS-2: Reduce coronary heart disease deaths.
IVP-1: Reduce fatal and non-fatal injuries.

Building Professional-Community-Client Partnerships in Rural Settings

Case management
Community-oriented primary health care
Health care reform initiatives are focusing on cutting costs while improving access to care with equitable quality for all citizens, especially vulnerable and underserved populations. State and local grass roots organizations must be actively involved if health care reform succeeds in rural areas. Specifically, professional-patient-community partnerships are essential to accomplish reform at the local level. Nursing practice in rural areas is comprehensive and incorporates skills from nursing and public health. Two models have been found to be particularly useful for nurses in rural environments: case management and community-oriented primary health care (COPHC).

Risk and Vulnerability

Vulnerability
Compared with the general population some people are more sensitive to risk factors; this can effect their health usually for the worse.
Risk (Health conditions that result from the interaction of many factors)
genetic makeup
lifestyle
Physical and social environments
What is vulnerability
What are vulnerable populations in terms of health care?
Simply stated, vulnerable populations are those considered to be at greater risk for developing health problems. (Aday, 2001; Sebastian et al., 2002)

Root Causes

Socio economic status/poverty
Insurance coverage/uninsured and underinsured
Race and ethnicity
Prevalence of vulnerable population is difficult to measure due to overlapping of populations.

Characteristics for risk of Vulnerability

Have energy draining illnesses or conditions such as stroke, heart disease, cancer or depression
Are not included in the dominant culture
Have compromised language
Are unable to comprehend information
Have injury or illness that limits independence
Lack the ability to access services needed for everyday life
Are in a position of diminished visibility

Social determinants of Health

Are conditions of the environment into which people are born, live, work, play, worship, and age that can affect health status, function and quality of life.
Social norms or attitudes
Exposure to crime and violence
Social disorder
Concentrated poverty (Allender, 2014)

Populations at risk

Poor
Homeless
Very young
Elderly
Adolescent who are pregnant
Severely mentally ill persons
Substance abusers
Victims of abuse
Disabled

Web of Causation:

Is used as an approach to health and Illness
Disadvantaged socio-economic status
Life style behaviors
Low self esteem
Feelings of powerlessness
Disenfranchisement
Interaction between individual-assets, social-assets and demographic factors contribute to poor vs good health

Homelessness

Understanding homelessness requires a grasp of several social issues:
poverty
affordable housing,
disabilities, and others.
In January 2015, 564,708 people were homeless on a given night in the United States.
Of that number, 206,286 were people in families, and 358,422 were individuals.
About 15 percent of the homeless population - 83,170 - are considered "chronically homeless" individuals.
About 2 percent - 13,105 - are considered "chronically homeless" people in families.
About 8 percent of homeless people- 47,725 - are veterans (National Alliance to End Homelessness, 2016)

Homelessness

The National Alliance to End Homelessness states that there are 633,782 people experiencing homelessness on any given night in the US. 142,168 (22.1%) are children, 62,619 (13%) are veterans, and 269,991 (42.6%) are disabled and unable to work

Factors contributing to a person becoming homeless

Poverty
Lack of affordable housing
Job Loss
Lack of health care
Mental Illness
Substance abuse
Domestic Violence
Lack of education

Characteristics of Homeless Adults

28 percent of homeless adults were severely mentally ill
22 percent were physically disabled
18 percent were employed
15 percent were victims of domestic violence
13 percent were veterans
3 percent were HIV Positive (United States Conference of Mayors, Hunger and Homelessness Survey, 2014)

Common Health Problems of the Homeless

Mental health problems
Substance abuse problems
Bronchitis and pneumonia
TB
Problems caused by being outdoors
Wound and skin infections
HIV/AIDS

Homelessness

http://www2c.cdc.gov/podcasts/media/pdf/HIV_Homeless.pdf
New approach to the problem
http://www.pbs.org/now/shows/305/video.html
Snap shot on homelessness
http://www.endhomelessness.org/pages/snapshot_of_homelessness

Issues to consider

What are the issues of homelessness?
Chronic Illnesses and Socioeconomic variables
Hypertension
Diabetes
Cardiovascular disease
Economic Assets
Social Assets
Education
Family structure
Employment
Friendship ties
Neighborhood communities
Religious groups

Poverty

https://www.medicaid.gov/medicaid-chip-program-information/by-topics/eligibility/downloads/2015-federal-poverty-level-charts.pdf

Poverty Index

Determined by Calculating:
Cost of specific goods and services with in a given time frame.
Federal poverty index takes into account minimum/adequate diet for and individual.
Adjusted for size (number) and age of members in a household and place of residence.
Calculated annually by the DHHS and is based on the consumer price index

Federal or State Entitlement Programs

WIC (women infants and children)
Medicaid
Head start
Chip (state)
Pell educational grant
Federal Poverty Guidelines: Eligibility for Medicaid and Chip
133% of the federal poverty level

United States Department of Health and Human Services: (HHS Figure for Federal Poverty In 2015)

http://aspe.hhs.gov/poverty/15poverty.cfm

Hunger in the US

The U.S. Department of Agriculture's most recent annual assessment of household food security in the United States found that, for 2013, an estimated 14.3 percent of American households, or 17.5 million, were food insecure at least sometime during the year.

Food Insecurity

5.6 percent, or 6.8 million households, fell into the category of very low food security, meaning that the food intake of one or more household members was reduced and their eating patterns were disrupted at times during the year because the household lacked money and other resources for food.

Food Bank Vs Food Pantry

A foodbank is a non-profit, charitable organization that distributes food to those who have difficulty purchasing enough food to avoid hunger.
In North America and Australia, food banks usually operate on the "warehouse" model. They act as food storage and distribution depots for smaller front line agencies; and usually do not themselves give out food directly to the hungry. After the food is collected, sorted, and reviewed for quality, these food banks distribute it to non-profit community or government agencies, including food pantries, food closets, soup kitchen, homeless shelters, orphanages, and schools.

Three largest Federal Food and Nutrition Assistance programs

The Supplemental Nutrition Assistance Program
National School Lunch Program
Special Supplemental Nutrition Program for Women, Infants and Children. (WIC)
Falls under the department of agriculture

Philadelphia's Effort to Reduce Hunger

Food Policy Advisory Counsel (FPAC)
Neighborhood specific advisory guides
Food cupboards
Soup kitchens providing healthy food options; trainings for CPR, food safety
The Philadelphia Food Policy Advisory Council (FPAC) is creating neighborhood-specific Food Resource Guides that will include information on where to access food resources such as food cupboards, farmer's markets, SHARE Food Program host sites, after-school programs, feeding sites for seniors, summer food programs, and others. These guides will be distributed to the public via community-based service organizations, libraries, churches, and City Council offices. The guides will also be available online. FPAC is also working with soup kitchens to provide healthy food options and trainings that ranges from CPR to food safety. In the past year, Philadelphia has become more collaborative in its efforts to reduce hunger and provide healthier options to people needing assistance from food cupboards and soup kitchens. A wide range of community stakeholders is involved in these efforts, including local government agencies, corporations, televisions stations, emergency food providers, universities, community-based organizations, and individuals. FPAC is hopeful that this collaborative partnership will have a positive impact on reducing hunger in Philadelphia

Common Health Issues of the Homeless

Mental health problems
Substance abuse problems
Bronchitis and pneumonia
TB
Problems caused by being outdoors
HIV/AIDS
Wound and skin infections

Vulnerable Populations and Chronic Conditions

A key identifying characteristic of vulnerable populations is the presence of 1 or more chronic illnesses. Although certain chronic conditions, such as dyslipidemia, may not presently be disabling to the patient, they have potentially disabling effects in the future. In addition, although some individuals with chronic conditions live full, productive, and rewarding lives, others live with isolation, depression, and physical pain resulting from their illness.dyslipidemia is elevation of plasma cholesterol, triglycerides (TGs), or both, or a low high-density lipoprotein level that contributes to the development of atherosclerosis. Causes may be primary (genetic) or secondary. Diagnosis is by measuring plasma levels of total cholesterol, TGs, and individual lipoproteins. Treatment involves dietary changes, exercise, and lipid-lowering drugs.

Risk factors

Modifiable
Cigarette smoking
Diet
Physical inactivity
Obesity
Hypertension
Diabetes
Non modifiable
Ethnicity
Age
Gender
PHN need to identify modifiable risk factors and then develop a plan emphasizing prevention.
Wu, s. & Green, A. (2000). Projection of chronic illness prevalence and cost inflation. Washington, DC: RAND Health

Wagner's Chronic Care Model

Provides the essential element of the health care system that promotes optimal chronic disease care.
Community services implemented to meet needs of the client and avoid duplication.
Support self-help strategies (i.e. American Diabetes Association)
Case management
Cultural sensitivity
Health literacy

Development of care improvement goals

Chronic Disease
Feeling of fear
Issues of loss
Anxiety
Fatigue
Pain
Grief
Anger dependence helplessness
Often leading to sick role and chronic sorrow.

Role of the Public Health Nurse in caring for clients with chronic disease

Education and development of a plan of care
Participation in political activity
Involved in health care policy
Help clients make informed health decisions.
Support clients with powerlessness
Provide physical and emotional support

Diabetes and the Community

Bad Sugar
https://cloud.ensemblevideo.com/Watch/badsugar
General information on Diabetes
http://www.cdc.gov/diabetes/pdfs/data/2014-report-generalinformation.pdf

Diagnosed and undiagnosed diabetes in the United states

Total: 29.1 million people or 9.3% of the population have diabetes.
Diagnosed: 21.0 million people.
Undiagnosed: 8.1 million people (27.8% of people with diabetes are undiagnosed) (CDC, 2014)
Snap Shot of Diabetes in the United states
http://www.cdc.gov/diabetes/images/data/infographic-diabetes.png
Snap Shot of Pre Diabetes in the United states
http://www.cdc.gov/diabetes/pubs/statsreport14/diabetes-infographic.pdf
Snap shot of Hypertension in the United States
http://www.cdc.gov/bloodpressure/infographic.htm

Preventing Hypertension

http://www.cdc.gov/bloodpressure/healthy_living.htm
CDC Fact Sheet
http://www.cdc.gov/heartdisease/facts.htm

Signs and symptoms of a heart attack

Women and Cardiac disease
Effects more than 1 in 3 women in the US. Resulting in approximately 400,000 deaths each year.
Greater incidence of death vs men since 1984
Sign and Symptoms of Heart Attach in Women
Unusual fatigue
Sleep disturbances
SOB
Chest pain is sharp burning pain in neck, jaw, throat, abdomen, and back

Role of public health Nurse

Emphasize Prevention
Discuss and educate regarding estrogen and CVD
Discuss cardiac risk factors
Educate client in the use of medication and when to seek attention for chest pain

The Future Role of Community Health in Chronic Illness and Disability

Surveillance
Environmental modifications
Regulation
Clinical care and monitoring
Outbreak detection
Case management
Immunizations
Health education
Teen Pregnancy

Healthy People 2020 Objectives:

1.Increase the percentage of adolescents who have been tested for HIV
2.Increase the proportion of adolescents who receive formal instruction on reproductive health topics before they are 18 years old.
3.Increase proportion of adolescents who talk to a parent or guardian about reproductive health topics before they are 18 years old.
4.Reduce low birth weight and very low birth weight.
5.Increase the proportion of pregnant women who receive early and adequate prenatal care.

Factor contributing to Pregnancy in teens

1. Sexual activity
2. Peer Pressure
3. Sexual victimization
4. Coercive sex/ statutory rape

Levels of Prevention

Primary
Secondary
Tertiary

Special Issues when Caring for Pregnant teens

Violence
Initiation of Prenatal care
Low-birth weight and Preterm delivery
Nutrition
Infant care
Repeat Pregnancy
Schooling and education needs

Role of Nurse and teen pregnancy

Home visit
Assessment
Compliance with antepartum goals
Weight gain
Good nutrition
Prenatal medical concerns
Child care practices and assisting family through stages of reaction
Teen Pregnancy and Web of Causation
Case Study

Social and Community Factors Influencing Violence

Work
Education
Media
Organized religion
Population
Community facilities
Many factors in a community can support or minimize violence. Changing social conditions, multiple demands on people, economic conditions, and social institutions influence the level of violence and human abuse. The following discussions of selected current social conditions help to explain factors that influence violent behavior.

Work

Work-associated links to violence
Unemployment
Changing patterns of employment
Frustration with jobs that are repetitive, boring, and lacking in stimulation

Bullying

Forms
Physical
Psychological
Intimidation
Verbal
Exclusion
Occurs across ethnicities and ages
Antecedent to domestic violence

Effects of Population

Contributions to violence
Density, poverty, and diversity, particularly racial tension and overt racism
Power and control
Patients are coming to the ER due to the physical violence as well as the stress of being of that situation and health implications that result from that
One's perception of safety in a community
Can be influenced by racism and perceptions of criminality
High-population-density communities
Gangs
There are certified gangs specialist about culture within gangs and the behaivor
Highly diverse populations
Differences may become disruptive.

Community Facilities

Availability of resources and facilities
Recreational facilities, such as playgrounds, parks, swimming pools, movie theaters, and so on
Spectator sports
Absence of facilities can increase likelihood of violence.

Violence Against Individuals or Oneself

Homicide (murder)
Rate for males nearly four times that of females
Non-Hispanic blacks account for nearly half of deaths by homicide
Assault (serious bodily harm, rape, kidnapping)
Rape
One of most underreported forms of human abuse
Posttraumatic stress disorder (PTSD)
Attitudes
Pornography
Victim or survivor?
Suicide
Women are the largest group that are going to commit suicide but men are largest group that actually carry it out

Family Violence and Abuse

Development of abusive patterns
Upbringing
Increased stress
Types of intimate partner and family violence
Physical
Sexual
Child Abuse
Foster care
Indicators of child abuse
Passive neglect
Emotional abuse
Child neglect
Physical, emotional, medical, and educational
Sexual abuse
Abuse of Female Partners
Terminology
Intimate partner violence is more inclusive than spouse abuse or wife abuse.
Signs of abuse
Physical marks
Low self-esteem, depression, PTSD
Abuse as a process
Victim initially downplays/denies seriousness; period of self-blame; moral conflict: leave or stay?
As violence escalates, abuser's remorse lessens
Moment of leaving the relationship is moment of greatest risk for homicide

quick recall 7

Which behavior most accurately reflects the predictable pattern of intimate partner abuse?
A. Low self-esteem is always a sign of abuse.
B. The most dangerous point in the relationship is the moment of leaving the relationship.
C. As abuse spirals, the abuser has mounting self-blame, which only contributes to greater loss of control.
D. Abusers undergo a moral dilemma of whether to leave or to stay; it is this frustration that fuels uncontrolled anger.
Answer is B
Get That?
The moment of greatest risk of homicide in an abusive intimate relationship is the moment the victim actually leaves the relationship. Although low self-esteem is often a sign of chronic abuse, not everyone who has low self-esteem is being abused. It is more often the victim, not the abuser, who initially goes through a period of self-blame. Later, as concerns grow, he or she faces a moral conflict: leave or stay? Finally, as violence escalates, an abuser's remorse lessens.

Public Health Nurse's Role

Partnering with the community
Understand cultural differences.
Lead in planning, implementing, and evaluating programmatic change.
Screening
Use of effective screening protocols, institutional support, staff training, access to services/referrals
Safety planning

Issues in Public Health Nursing: Violence and Human Abuse

You may recall that Marcus works with helping batterers recover and gain control in order to break the cycle of violence.
"A lot of my patients attend our program because they are mandated by the courts. Recovery can be spotty. However, the good news is that some come because they are truly motivated to change; many want to save their relationships; others just want to stop."
Pause here to predict what you think would make for maximum success with this high-risk population.

Public Health Nurse's Role

Batterers' interventions
Often effective for motivated individuals
Most effective if they—
Are part of a coordinated community response
Involve appropriate risk assessment and management practices
Are of adequate structure and duration
Are court mandated and closely monitored
Involve training and close supervision of the staff implementing the program
Red flags:
Abuser is present
Speaks for the partner
Refusing to leave
Bruises and the story behind it

Types of Violence Against Female Partners

Intimate partner sexual abuse
May not be recognized as a form of abuse
Abuse during pregnancy
Heath implications for the woman
Greater risk for sexually transmitted diseases (STDs) (condom refusal)
Risk of spontaneous abortion/premature delivery
Increased risk for depression and substance abuse
Health risks for infant
Spontaneous abortion
Premature delivery
Low birth weight
Small for gestational age
Drug exposure in utero

Elder Abuse

Types of elder abuse
Physical, sexual, emotional, financial/material abuse; neglect; abandonment
Prevention
Increased training in screening and awareness
Screening
Evidence-based guidelines available at Hartford Center: www.nursing.uiowa.edu/Hartford/nurse/ebp.htm

Nursing Interventions

Primary prevention
Assessment for risk factors
Individual and family strategies
Secondary prevention
Effective screening of families and individuals
Telephone crisis lines
Respite care
Tertiary prevention
Nursing actions: therapeutic family interventions
Nursing interventions specific to female partner abuse
How do we look to care with regard for caring for the abuser?

What is a risk factor?

A risk factor is something that increases your chance of getting a disease.
The more risk factors for coronary heart disease that you have, the greater your
chance of getting the disease.

What are the risk factors for coronary heart disease?

Some risk factors are called modifiable, because you can do something about
them. There are other risk factors, called non-modifiable, which you can't change.
However, many non-modifiable risk factors can be controlled and their effect
reduced by making changes to your lifestyle.

What are the modifiable and non-modifiable risk factors?

Modifiable risk factors include:
Smoking
High blood pressure
Diabetes
Physical inactivity
Being overweight
High blood cholesterol.

The good news is that the effect of many risk factors can be changed (you cannot
change the risk factor, only its effect). The effect of these modifiable risk factors
can be reduced if you make lifestyle changes.

Non-modifiable risk factors are:

Age
Ethnic background
Family history of heart disease

Age
The older you are, the more likely you are to develop coronary heart disease or to have a cardiac event (angina, heart attack or stroke).

Ethnic background

Family history

Your own risk of developing coronary heart disease is increased if: your father or brother was diagnosed with the disease, or had a cardiac event under the age of 55 your mother or sister was diagnosed with the disease or had a cardiac event under 65.

If you have a family history of heart disease, it may help to reduce your own risk if you look at what the risk factors affecting your family member were. Ask yourself:

Did they smoke?
Were they overweight?
Did they have a diet high in saturated fat?
Were they physically inactive?
Did they have diabetes?

If the answer is yes to one or more of these, then you can reduce your risk by making sure your lifestyle is not the same as theirs. Some risk factors, such as being overweight, are sometimes related to lifestyle habits that are passed on from one generation to the next. However, it's also likely that genes are responsible for passing on the risk of developing coronary heart disease. Genes can also pass on other conditions, such as high blood pressure orhigh cholesterol levels. Both of these conditions increase the risk of getting coronary heart disease.
Background information

Is there anything else which affects your risk?
People's income and the type of jobs they do, all appear to have an effect on how likely they are to get coronary heart disease. For example, people who work in manual jobs have a higher rate of coronary heart disease than people in other jobs, and people who live in poorer areas or are on lower incomes are also more likely to get the disease. Recent studies have also shown that individuals that lack support in their working environment may also be more at risk of developing coronary heart disease. Recognizing and dealing with stressful situations will help to prevent individuals using bad habits, such as smoking, drinking and eating more, to deal with stress.
Diabetes is classified as a modifiable risk factor. However, if you have diabetes, you cannot cure it. This means that anything that you can do to modify your lifestyle and keep your diabetes under control will help to reduce your risk of having a heart attack or developing angina. Having diabetes intensifies the effects of other risk factors that you may have, so it is important to reduce the risk of developing it.
While a family history of coronary heart disease is non-modifiable, i.e., if you have a family history of coronary heart disease, you cannot change it, making changes to your lifestyle will significantly reduce the risk of you developing coronary heart disease prematurely.

Anatomy and Physiology Skin

Function
Physical barrier/protection *Sensation
Temperature maintenance *Immunity
Fluid/electrolyte balance *Vitamin D synthesis
Absorption *Personal identity
Excretion *Wound repair
skin, hair, nails external structures that serve variety of functions. Skin is a physical barrier that protects underlying tissues and structures from microorganisms, physical trauma, ultraviolet radiation, dehydration; temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, Vitamin D synthesis; contributes to individual identity as big part of appearance
Epidermis-outer layer of skin, properties make the skin waterproof, melanin production; skin color depends on the amount of melanin and carotene contained in the skin and the volume of blood containing hemoglobin that circulates in the dermis
Dermis-connected to the epidermis by dermal papillae (form base of swirls or friction ridges that form unique pattern of fingerprints; ridges also appear on palms, toes , soles of feet), well vascularized, composed of connective tissue, made up of collagen, elastic fibers, nerve endings, lymph vessels; origin of hair follicles, sebaceous glands - secrete oily substance called sebum that lubricates hair and skin and reduces water loss through the skin, also has some fungicidal and bactericidal effects; sweat glands - two types; eccrine located over the entire skin surface, secrete odorless, colorless fluid, vital to regulation of body temperature; apocrine concentrated in axillae, perineum, areolae, open through a hair follicle, secrete milky sweat that interacts with skin bacteria producing body odor
Subcutaneous tissue- loose connective tissue- role in heat regulation, vascular pathways for supply of nutrients and removal of waste from the skin
How to document it?
Length x width x depth
What kind of exudate (drainage?
Color?
Oder?
Skin around the wound
Is it red, pink?
Is it blanched?
Wound itself?
Is it eschar?
Is there tunneling
Three layer structure
Epidermis
Outer layer
Provides waterproofing
Melanin (brown pigment) production
Dermis
Vascular, connective tissue layer *Lymph Vessels
Nerve endings *Hair follicles
Sebaceous (sebum/oil) glands *Sweat glands
Dermal Papillae
Subcutaneous Tissue/ Hypothermis
Epidermis: Outer layer
Provides waterproofing
Melanin (brown pigment) production
"Epidermis." Epidermis-delimited.jpg. Public Domain. Accessed 1/30/2014. URL=<<http://commons.wikimedia.org/wiki/File:Epidermis-delimited.JPG>>
Dermis
Vascular, connective tissue layer
Lymph Vessels
Nerve endings
Hair follicles
Sebaceous (sebum/oil) glands
Sweat glands
Dermal Papillae
Subcutaneous Tissue/ Hypothermis
Fat cells
Blood vessels
Nerves
Remaining portion of sweat glands

Aging on skin

Increase in skin atrophy, decrease in elasticity
70-80's skin thin, lax, dry and wrinkled - loss of collagen, decrease muscle tone, decrease sweat gland production, decreased melanin production, decreased vascularity
Find this under abnormal findings also
70-80's skin thin, lax, dry and wrinkled - loss of collagen, decrease muscle tone, decrease sweat gland production, decreased melanin production, decreased vascularity
Increase in skin damage
Sun Exposure
Sedentary Lifestyle
Nutrition
Environmental factors
Cigarette Smoking
Alcohol
Decrease in Testosterone
Females - decrease in estrogen
Atrophy - thin, dry transparent epidermis with loss of surface markings
Secondary to loss of collagen and elastin
Increased visibility of underlying blood vessels
Aged skin, arterial insufficiency

Wound Healing

Types of Wound Healing
Primary Intention
Secondary Intention
Tertiary Intention
Phases of Wound Healing
Inflammation
Proliferative
Remodeling
Remember
Although a wound may completely heal, the injured area will never regain its original strength.
Care to not re-injure!

Wounds

Types of wounds typically cared for in the home:
Acute/Chronic:
Acute Chronic - DM population
Origin
Process
Length of Time
Patient Assessment
Health History:
Disease Process
Medications Past and Present
Radiation
Nutrition/Hydration
Lab Data: Serum Albumin
Lymphocyte Count

Wound Assessment

Location
Dimensions LxWxD in cm.
Stage?
Undermining
Sinus Tract/Tunnelling
Tissue Viability
Granulations Tissue
Granulating with poor Blood supply
Epithelized Tissue
Slough
Eschar
Necrotic
Pain
Infection
Peri wound
Exudate
REEDA- Wounds, Incision description
COCA- Description of drainage
Lower extremity
Venous
Arterial
Mixed
Neuropathic- Diabetic/spinal cord injuries
Characteristics
Venous - more irregular in nature Arterial - more rounded in nature Neuropathic
Location
Pain
Pulses
Skin
Site
Depth
Shape
Characteristics
Venous Arterial Neuropathic
Size
Edge
Floor
Drainage
Edema
ABI
ABI Ankle Brachial Index
Ankle Systolic BP divided by Brachial Systolic
Venous: > 0.8
Arterial: < 0.8
Interventions
Venous Arterial Neuropathic

Pressure Ulcers

Causes
Risk Assessment Tools:
Norton 1961
Gosnell 1973
Braden 1987*
Staging
Only stage pressure ulcers; not incision, Diabetic or Venous stasis
Never stage backward
"Healing stage 4"
Stage 1: No breakdown; intact
Stage 2: Scratches, blisters; abrasions; Break in skin with red pink base; no slough
Stage 3: Through the dermis; yellow slough; gray; can have tunneling/undermining
Stage 4: Muscle, bone and or tendon; slough; can have tunneling/undermining

Interventions

Relieve Pressure
Nutrition
Cleansing
Exercise
Debridement:
Autolytic
Wet to dry technique
Not often used
Enzymatic
Mechanical

Management of Exudate

Dressing products should support moist wound healing
Not traumatize healthy granulation tissue or periwound skin
Comfort and reduce pain
Prevent infection
Selection Criteria
Simple
Ease of procedure
Frequency of changes
Availability of product
Cost
Caregiver abilities
Goals
Promote healing
Patient comfort
Prevention of complications
Products
Tegaderm to stage 1 to watch
Duoderm to ulcers, stage 2
Calcium Algonate for absorption
Aquasel for highly absorbent needs.
VAC Stage 3 and 4 pressure ulcers
Silver Alginate for Infection

Definitions

Migrant farmworker
Travels to do farm work; unable to return to permanent residence within the same day
A migrant farmworker is a seasonal farmworker who has to travel to do the farm work and is unable to return to a permanent residence within the same day.
Seasonal farmworker
Returns to permanent residence each day; works in farming at least 25 days or part-days per year; but does not work year-round in agriculture
A seasonal farmworker returns to his permanent residence, works in agriculture for at least 25 days or parts of days, and does not work year-round only in agriculture.

Migrant Lifestyle

Travel throughout the country seeking employment
Uncertainty regarding work and housing
Isolation in new communities
Lack of resources
Three migratory streams:
Eastern, originating in Florida
Midwestern, originating in Texas
Western, originating in California

Housing

Housing issues
Trouble locating available, decent, and affordable housing
May live in cabin, tent, house, apartment, car
Housing Assistance Council
52% of farmworker housing units are crowded.
More than half lack showers, laundry facilities, or both.
Ergonomic issues

Health and Health Care

Limited literature available
High risk for the following conditions:
Chronic disease
Poor dental health
Mental health problems
Higher rates for certain diseases
Tuberculosis, anemia, diabetes, hypertension
High levels of work injuries and chemical exposures
Detrimental physical and social environments for children
Accurate morbidity and mortality data are difficult to obtain because of many factors, such as Mexican-born farmworkers who return to Mexico when no longer working or go back to Mexico to receive services, and because infectious diseases, which are easier to record, are decreasing.
Homeless families that go from shelter to shelter and often times they may go to different school districts and they don't have the consistency of education

Access to Health Care

Health access limitations
Lack of knowledge about services
Inability to afford care
Availability of services
Transportation
Hours of service
Mobility and tracking
Discrimination
Documentation
Language
Cultural aspects of health care

Occupational and Environmental Health Problems

Agriculture work
Among the most dangerous U.S. industries
Highest fatality rate for foreign-born workers
Occupational health risks
Injuries
Exposure to chemicals (pesticides)
Inadequate surveillance system
Physical demands

Health Problems

Common Health Problems
At risk for health disparities
Lack of prenatal care
Food insecurity
Means that at certain point in tome people are rationing what they are having
Specific Health Problems
High prevalence of diabetes
Three to five times greater than general population
Dental disease
Mental health
Stress
Depression
Anxiety
Drug and alcohol use/abuse
Tuberculosis
HIV/AIDS

Quick recall 8

As a public health nurse working with migrant workers, Miriam is keenly aware that her clientele are at increased risk for certain diseases, such as the following:
A. Cirrhosis of the liver
B. Breast cancer
C. Tuberculosis
D. Glaucoma
Answer is C
Get That?
Migrant farmworkers exhibit higher rates for certain diseases, such as the following:
Tuberculosis
Anemia
Diabetes
Hypertension

Children and Youth

Malnutrition
Infectious diseases
Dental caries
Inadequate immunization status
Pesticide exposure
Injuries
Overcrowding and poor housing conditions
Disruption of their social and school lives, leading to anxiety problems
Obesity, high blood pressure, stunting, anemia in older children
Migrant farmworker parents want a better future for their children.
Federal law does not protect children from overworking or from the time of day they work outside of school.
Cultural Considerations in Migrant Health Care
Nurse-client relationship
Health values
Health beliefs and practices

Nurse-Client Relationship

Nursing's image
Considered an authority figure who should respect the individual, be able to relate to the individual, and maintain the individual's dignity
Communication challenges
Nurse should try to validate that the client understands what the nurse is telling him or her
Hierarchy of health care consultants
Mexican clients may not seek health professional care first.
Instead consult with family, friends, or folk healers

Common Health Values of Mexican Communities

Family's influence
Significant part of Mexican individual's health care and social support system
Females as caretakers; males as decision-makers
Love of children is central.
Other Mexican individual with similar health problem may be more influential than the health professional
Religion may influence health practices.

Health Beliefs and Practices

Health may be considered a gift from God.
A healthy person is one who can continue to work and maintain one's daily activities independent of symptoms or diagnosed diseases.
Four common folk illnesses
mal de ojo (evil eye)
susto (fright)
empacho (indigestion)
caida de mollera (fallen fontanel) - dehydration in infants
Bulging fontanel - first sign is that the child is going to be irritable and then late sign is sleeping, sunset eyes, vomiting
Spinal Bifida
When experiencing a folk illness, the traditional Mexican individual would prefer to seek care with a folk healer. The more common healers are the curanderos, herbalistas, and espiritualistas. The most commonly used herbs are chamomile (manzanilla), peppermint (yerba buena), aloe vera, nopales (cactus), and epazote.

Health Promotion and Illness Prevention

Health promotion and disease prevention may be difficult concepts for migrant workers to embrace for the following reasons:
Their beliefs regarding disease causality
Their irregular and episodic contact with the health care system
Their lower educational level
Ask worker/families which health topic interests them
Nurses can be part of the planning and education of health workers for outreach educational programs. Evaluation to determine successful outreach educational methods can be undertaken by nurses. These activities demonstrate the core competencies related to the domain of community dimensions of practice skills for public health nursing. The skills include recognizing community relationships affecting health, collaborating with community partners to promote the health of the population, using group processes to advance community involvement, identifying community assets and resources, and promoting public health programs.

Levels of Prevention

Primary
Teach migrant workers how to reduce exposure to pesticides
Secondary
Conduct screening for diabetes in adult farmworkers and for children in camps.
Tertiary Prevention
Educate migrant families regarding appropriate nutrition for an adult with diabetes or child with anemia.
Role of the Nurse
Social and political advocate for migrant populations
Community educator
Screening and monitoring activities

Historical Overview

Alcohol prohibition from 1920 to 1933
Sharp increase in violent crime and corruption
War on drugs and prohibition on marijuana, cocaine, and other drugs
Increase in violent crime and reports of corruption among law officials
Drug war budget grows each year
Most of it goes to law enforcement and punishment.
Only a third goes toward prevention and treatment.

Issues in Public Health Nursing:Addiction Challenges

Emilia says, "Growing up in a family with lots of addiction challenges, I have always had this sense that I could communicate, I could relate, you know? So when a position opened up at a local drug control treatment center, I applied. My particular position focuses mostly on tertiary prevention—you know, detox and addiction treatment.
"However, we also run secondary programs like drug testing and outreach to high-risk groups, family therapy for codependency, and some primary prevention in the schools."

Attitudes
"Good" drugs
Over-the-counter (OTC) drugs
Prescription drugs
"Bad" drugs
Illegal drugs
Perceptions of addicts: immoral, weak, or irresponsible persons who should try harder to help themselves
Nurses' self-assessment: examine own attitudes before working with clients

Myths

"An alcoholic is a skid row bum."
"If you teach people about drugs, they will abuse them."
"Addiction is a sin or moral failing."
Paradigm Shift
Shift from "war on drugs" to an approach that includes role of treatment
National drug policies need to be more comprehensive rather than focusing on law enforcement strategies.
Harm reduction model
Addiction is a health problem.
Any psychoactive drug can be abused.
Accurate information can help people make responsible decisions about drug use.
People who have alcohol, tobacco, and other drug problems can be helped.

Definitions

Alcohol, tobacco, and other drugs (ATODs)
Term is a reminder of which are the leading drug problems
Substance abuse
Use of any substance that threatens a person's health or impairs social or economic functioning
Psychoactive drugs
Drugs that affect mood, perception, and thought
Drug dependence
Neuroadaptation; a physiological change in the central nervous system caused by the chronic, regular administration of a drug
Withdrawal
Symptom set caused by discontinuing a substance
Drug addiction
Pattern of compulsive use of a drug to avoid withdrawal symptoms
Alcoholism
Addiction specific to alcohol

Quick Recall

Matt, one of Emilia's patients, was prescribed morphine for pain after a car accident, but he found that it was difficult to get off the drug, especially since it also distracted him from depression that resulted from loss of his daughter in the accident. As his physician began tapering him off the morphine, Matt began using several different doctors to get access to a variety of prescription painkillers. His initial reaction to morphine can be described as which of the following?
A. Withdrawal
B. Drug addiction
C. Substance abuse
D. Drug dependence
Answer is D

Get That?

Drug dependence is a physiologic change in the central nervous system (CNS) caused by the chronic, regular administration of a drug. Although it leads to a state of neuroadaptation, it differs from drug addiction and substance abuse, which are driven by intense cravings. Both are associated with symptoms of withdrawal on abrupt discontinuation.

Psychoactive Drugs' Effects

Alcohol
Fetal alcohol syndrome (FAS) or fetal alcohol effects (FAEs)
Tobacco
Mainstream smoke
Sidestream (second-hand) smoke
Marijuana
Potential respiratory tract damage
Illicit prescription drugs
Growing area of concern; overdose death rates have more than tripled in the United States since 1990

Predisposing/Contributing Factors

1. Drug
2. Set: user and user's expectations
3. Setting: user's environmental influences

Set The individual's expectations include unconscious expectations about the drug being used.
Current health may alter a drug's effect from one day to the next.

Genetic predisposition
Underlying mental illness
Setting
The influence of the physical, social, and cultural environment within which the use occurs
Factors include the following:
Daily stressors
Advertisements
Lower socioeconomic background
Lack of education
Limited employment possibilities

Primary Prevention

Promotion of healthy lifestyles and resiliency factors
Drug education
Issues in Public Health Nursing:Addiction Challenges
Emilia works mostly in tertiary prevention, specializing in the following types of services:
Detoxification
Addiction treatment
Smoking cessation programs
Support groups
The center also provides primary prevention in the following forms:
Promotion of healthy lifestyles and resiliency factors
Drug education

Secondary Prevention

Assessing for alcohol, tobacco, and other drug problems
Drug testing
High-risk groups
Adolescents
Older adults
Injection drug users
Drug use during pregnancy
Persons who use illicit drugs
Codependency and family involvement

FRAMES Interventions

Feedback: provide the client direct feedback about the potential or actual personal risk or impairment related to drug use
Responsibility: emphasize personal responsibility for change
Advice: provide clear advice to change risky behavior
Menu: provide a menu of options or choices for changing behavior
Empathy: provide a warm, reflective, empathetic, and understanding approach
Self-efficacy: provide encouragement and belief in the client's ability to change

Outcomes

Nurses can do the following:
Assess the health of the community and its citizens.
Prioritize needs.
Identify local resources.
Collaborate with others to develop strategies that will improve the underlying health of the community.
Early identification and intervention for persons with ATOD problems—
Can prevent many harmful physical, emotional, and social consequences
May prevent abuse patterns from developing into addiction

Mental Health

Ryan heads a task force in his city that is fighting to reduce the number of mentally ill people who've been left homeless on city streets and parks. In addition to expanded protective housing for this population, Ryan's team also focuses on the following:
Day centers to provide a sense
of community and support
Education programs for family
members and clients, including
combined support groups
"I feel strongly committed to our
clientele," Ryan says, "but a
large part of my job involves
coordinating the efforts of our
multidisciplinary team."

Scope of Mental Illness in the United States

Consumer advocacy
Neurobiology of mental illness
Scope of Mental Disorders
Leading cause of disability in North America
Function impaired from mental illness
18% of U.S. adults
3.9% of these have serious mental illness.
8.1% of these also have substance abuse.
Teens (12-17) with major depressive disorder
14% of females
7% of males
18% of U.S. adults have a mental health condition serious enough to impair function.
By 8th grade, 24% of adolescents have ingested alcohol, and by 12th grade, 64% are drinking (SAMHSA, 2013).
Nearly 17% of people over age 55 have a mood or anxiety disorder (Byers et al, 2010), and these rates will rise as the number of older Americans increases over the next two decades.
Alzheimer's disease, the primary cause of dementia, affects about 5.2 million Americans each year and creates a significant mental health burden for individuals and families.

Consumer Advocacy

National Alliance for the Mentally Ill (NAMI)
Established education and self-help services for individuals and families
Garnered support from political and legislative bodies
Community Support Program (CSP)
National Institute of Mental Health (NIMH)
Provided grant monies to states to develop comprehensive services for persons discharged from psychiatric institutions and invited consumers to participate

Systems of Community Mental Health Care
Managed care

Controls cost and access to appropriate care
Expensive comprehensive services are still less expensive than frequent hospitalizations.
Patient Protection and Affordable Health Care Act (ACA)
Ensures access to mental health services to 27 million more Americans
Increases the need for community health nurses

Mental Health Services

Community mental health model
Primary method of care for serious and persistent mental illness
Components: team care, case management, outreach, rehabilitative and recovery approaches to help prevent exacerbations of illness
Community mental health centers
React to societal, political, and fiscal pressures. As resources diminish, many CMHCs are unable to provide services beyond the most serious and persistent mental illnesses.

Issues in Public Health Nursing:Mental Health

Ryan feels his challenges are constantly changing.
"I'm haunted sometimes," he says, "by how short on funding we always run, and every year government funds for our programs only seem to get smaller. It frustrates me that we are often only able to serve the most seriously ill. We're doing a lot less preventive care than we used to, which frustrates me because I firmly believe that prevention in the long run is cheaper than crisis interventions and hospitalizations."
Hospital Expansion, Institutionalization, and the Mental Hygiene Movement
20th and 21st centuries
Mental hygiene movement (prevention, early intervention, social/environmental influences)
Clifford Beers urged reform and influenced the founding of the National Committee for Mental Hygiene.

Community health model

Deinstitutionalization
Transition from state hospitals to communities
Cost was motivating factor
Other causes: psychotropic drugs and civil rights
Unexpected gaps, continuity-of-care problems
Jail was called "re-institutionalization."
Civil rights legislation for persons with mental disorders
Americans with Disabilities Act of 1990
Advocacy Efforts
National Alliance for the Mentally Ill (NAMI)

Conceptual Frameworks for Community Mental Health

Biopsychosocial theories
Identify multidimensional aspects of community mental health nursing; explain biological processes, systems, personality, life span development, family dynamics, and stress and coping; focusing on wellness or recovery
Systems theory
Understanding of the whole occurs through understanding relationships that exist between the parts; a holistic view of system and subsystems
Levels of prevention
Primary: reduction of health risks
Secondary: reducing prevalence or nature of a condition
Tertiary: attempts to restore and enhance function
Relapse management
Assertive community treatment (ACT) programs
Medical team approach; 24 hours a day, 7 days a week
Psychosocial rehabilitation
Intensive case management
Contact several times a week by an individual case manager

Quick Recall

One of Ryan's patients moves from the hospital to a program based on a medical model in which she works with a team who provide crisis and case management services 24 hours a day, 7 days a week. She has most likely entered a(n):
Secondary prevention program
Intensive case management program
Assertive community treatment
program
Psychosocial rehabilitation
program (sometimes referred
to as a "clubhouse")
Answer is C

Get That?
Assertive community treatment (ACT) programs differ from intensive case management approaches in that they are based more on a medical model and team approach and provide crisis and case management services 24 hours a day, 7 days a week. They are sometimes referred to as hospitals without walls.

Multiple Roles of the Nurse in Community Mental Health

Clinician
Use nursing process to guide diagnosis and treatment of human responses to mental health
Problems
Biopsychosocial interventions
Milieu management
Assistance with self-care
Multiple Roles of the Nurse in Community Mental Health (Cont.)
Educator
Teaching clients about symptom management
Teaching clients the benefits of using and staying on meds
Educational programs for family members
Combined support and education groups
Multiple Roles of the Nurse in Community Mental Health (Cont.)
Coordinator
Coordination of multidisciplinary team
Programs to promote independence
Programs to promote self-care
Current and Future Perspectives
Nationally and internationally, there are too few mental health care services.
Patient Protection and Affordable Health Care Act passed in 2010

Current and Future Perspectives
Nationally and internationally, there are too few mental health care services.
Patient Protection and Affordable Health Care Act passed in 2010

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