ATI Proctored Exam: Community Health (Public Health)

*Nightingale's Theory of Environment*: Focuses on impact of a person's environment on their health. Focus in on preventative care (washing hands, clean environment). *Health Belief Model*: Assumes a persons primary motivation in taking positive health actions is to avoid getting a disease. *Likelihood of taking action is based on*: 1. Modifying variables (age, gender, race, economy, education) 2. Perceived severity and susceptibility of getting the disease 3. Perceived benefits vs. barriers of taking action 4. Cues to action (i.e. advice of doctor, media campaign)

The community or population is the "client" in community health nursing. *Community-Based Nursing*: Focused on ILLNESS care (acute or chronic conditions) for individuals and families. - Examples: Home Health nurse doing wound care, School nurse administering epi-pen. *Community-Oriented Nursing: Focused on improving the collective health of the community. - Examples: Health education and promotion, disease prevention activities. No illness care! Community-oriented nursing = public health nursing.

*Community Health Nursing*: Delivers health care services to individuals, families, and groups. Includes community-based nursing (illness care for individuals and families) AND community-oriented nursing (community focused care, with an emphasis on education and disease prevention). *Public Health Nursing*: Disease prevention and health promotion of communities and populations. They re not providing direct care to individuals! Public health nursing = community-oriented nursing.

*Respect for Authority*: Respect a patient's right to self-determination. *Non-Maleficence*: Do no harm *Beneficence*: Do what is best (i.e. maximize benefits) *Distributive Justice*: Fair allocation of resources in community.

*Epidemiology*: Study of spread, transmission, and incidence of disease/injury. *Components of Epidemiology Triangle* - *Agent*: What is causing the disease (i.e. bacteria, toxin, noise) - *Host*: Human/animal being affected by the disease - *Environment*: Physical environment (water/food supply, geography). Social environment (access to health care, work conditions, poverty).

*Incidence*: Number of NEW case of disease/injury in a population during a specified period of time. *Prevalence*: Number of ALL cases (new and pre-existing) of disease/injury in a population during a specified period of time.

*Community Health Education* - *Obstacles*: Age culture, illiteracy, language barriers, lack of access, lack of motivation. - *Learning Styles*: visual (video, presentations), auditory (verbal lectures, discussions), tactile-kinesthetic (hands-on, return demonstration). *Healthy People 2020*: Includes national health goals based on major risk to health and wellness of U.S. population (i.e.: Diabetes,Cancer, Older Adults, LGBT health).

*Primary Prevention*: Prevents initial occurrence of disease. - i.e. education, immunizations, prenatal classes. *Secondary Prevention*: Focuses on early detection of disease, limiting severity of disease. - i.e. screenings, disease surveillance, control of outbreaks. *Tertiary Prevention*: Maximize recovery after an injury/illness. - i.e. rehabilitation, PT/OT, support groups

*Acculturation*: Adopting the traits of a different culture. *Ethnocentrism*: The belief that one's own culture is superior to all others. View world from their own cultural viewpoint. *Culture Assessment*: Ask about patient's ethnic background, religious preference, family structure, food patterns, and health practices. Incorporate patient preferences into care whenever possible. *Interpreter*: Use of family members in not recommended, interpreters need to have knowledge of health terminology. Patient teaching materials should be available in their primary language.

*Environmental Risks* - *Toxins* (i.e. lead, pesticides, asbestos, radon) - *Air pollution* (i.e. carbon monoxide, tobacco smoke, lead) - *Water pollution* (i.e. waste products, chemical runoff from soil) *Environmental Assessment Questions*: - Condition of housing. Remodeling activities? - Water heater temperature less than 120 degrees F? - Tobacco smoke present in home? - Quality of drinking water?

- Pre-1978 housing at risk for lead-based paints!! - Screen children 6 months - 5 years for blood lead levels. - Avoid playing in soil right outside home. - Wet mop floors 9vs. vacuuming floors) - Use wet sanding technique (vs. dry sanding) - Make sure children get enough iron and calcium in diet, as this decreases absorption of lead in the body. - Use cold water (vs. hot water) because lead dissolves more quickly in hot water.

*Medicare Eligibility*: - Older than 65 years old - Receiving disability for at least two years - Diagnosed with Amyotrophic Lateral Sclerosis (ALS) or End-stage Real Disease (ESRD) and receiving dialysis. - *Part A*: Inpatient hospital, limited SNF, home health care. - *Part B*: Outpatient care, diagnostic services, PT/OT. - *Part C*: Combines part A and B, provided through private insurance. - *Part D*: Prescription drug coverage ( Think D for drugs). *Medicaid Eligibility*: Those with low socioeconomic status and no other insurance, based on household size and income.

*State Health Department*: manages WIC program, CHIP, Medicaid program. Reports notifiable communicable disease to CDC (voluntary). *State Board of Nursing*: Licenses LPNs and RNs, oversees state schools of nursing, develops state's nurse practice act. *Local Health Department*: Meets health needs of community. Reports notifiable communicable diseases to State Department of Health.

*People* - Demographics - Biological factors (race, age, gender, health/disease status) - Social factors (education, income, crime rate) - Cultural factors (history, religion, customs) *Environment*: Physical factors (geography, housing, location of health care services) - Environmental factors (climate, pollutants, topography)

*Informant Interviews*: Direct conversations with member of community. *Community Forum*: public meeting (participation challenges) *Secondary Data*: review existing data available (statistics, health records). *Participant Observation: observe community activities. *Windshield Survey*: drive through community and make observations. *Focus Groups*: meet with representative sample of community. *Surveys*: written format (expensive, low response rate).

*People*: General appearance, ethnicity/race of community members. Signs of violence? Mental illness? Drug abuse? *Place*: Quality of housing, access to health care facilities, types and availability of grocery stores, public transportation, presence of schools, parks, and churches.

*Pre-planning*: Brainstorm ideas *Assessment*: Data collection *Diagnosis*: Analyze collected data to determine health needs of the community. Set priorities. *Planning*: Plan interventions. Establish goals, identify responsibilities, develop budget. *Implementation*: Execute plan. *Evaluation*: Determine effectiveness of intervention.

- Provides health care in patient's homes and assisted living facilities (including nursing homes). - Provides patient education, direct nursing care, and *care coordination* (including referrals) - Assesses home for safety. Key items to look for -- *NO scatter rugs* (carpet OK), no clutter, adequate lighting on stairs (use of colored tape on step edges is helpful). For Alzheimer's patients: locks/alarms on exit doors are appropriate.

*Hospice Nurse*: Provides palliative care (focus on *symptom management*, not curing disease), supports patient and family with dying process. *Parish Nurse*: Works with pastoral staff to improve the health and wellness of the faith community. Provides health education and facilitates support groups. Does *NOT* do bedside nursing tasks.

- Promotes health and wellness of employees, prevents workplace illness and injury. - Through surveillance, identifies risks within work environment. Identifies ways to decrease or eliminate workplace hazards. - Keeps informed about OSHA standards. *Primary Prevention*: provides safety education. *Secondary Prevention*: Perform screenings. *Tertiary Prevention*: sets up limited-duty programs.

- Provides direct nursing care to children at school. - Provides health education. - Case manager for children with health needs (makes referrals, schedules appointments, coordinates services) *Primary Prevention*: Assesses immunization status of children. *Secondary Prevention*: Provides vision and hearing screening, screens for oral health, scoliosis, infestations. Assesses for child abuse/neglect. *Tertiary Prevention*: Administers medications, provides nursing care for children with chronic diseases, assess children with disabilities.

*Infants/Children*: SIDS (sleep on back), injuries (wear helmets and seatbelts), communicable disease (get immunizations). *Adolescents*: *Motor vehicle accidents (wear seatbelts)*, substance abuse (including smoking), safe sex, mental health. *Women*: Menopause, *osteoporosis (encourage weight bearing exercise*), heart disease, diabetes, cancer prevention (get mammograms, pap smears). *Men*: Heart disease, cancer prevention (*get prostate cancer screening*, testicular self exams), lung disease, liver disease. *Older adults*: Heart disease, CVs, COPD, pneumonia, polypharmacy, cancer, injury prevention (including falls).

*Transitions*: Includes birth or adoption of child, death in family, major illness, divorce, loss of income, etc. *Transitions = time of risk for family*. *Genograms*: Graphical representation of relationships within the family, patterns of illness (i.e. "enhanced" family tree). *Ecomaps*: Graphical representation of family interaction with outside groups/organizations, which provides information about the family's support network.

*Homocide*: often related to drug abuse, usually victim is someone known to perpetrator. Males at higher risk. *Rape*: Intimate partner violence vary common, often unreported. *Suicide*: Highest in men and those *over 65 years old*. *Abuse*: Physical abuse, sexual abuse, emotional abuse, (i.e. humiliation, intimidation), neglect (i.e. failure to provide food, shelter, emotional care, medical care, education), economic abuse (i.e. misuse of money, failure to provide for needs of victim despite adequate funds, theft).

*Community Factors that Increase Risk of Violence*: Unemployment, poverty, social isolation. Child abuse is more common when spousal abuse is present. *Signs of Child Abuse*: *presence of wounds or injuries in various stages of healing*, unexplained bruises/injuries, unusual fear of others, small round burns that could be caused by cigarettes, forearm spiral fractures. *Signs of Child Neglect*: Poor hygiene, inappropriate dress (for weather), signs of malnourishment, withdrawal, school absences.

*Factors that Affect Alcohol Metabolism*: Size/weight of drinker, time elapsed while drinking, gender, presence of food in stomach. *Alcohol Withdrawal*: *Manifestations appear within 4-12 hours*. Symptoms include: tachycardia, hypertension, nausea, vomiting, headache, anxiety, irritability, diaphoresis, tremors, seizures. It is important to ask patient when their last drink was! *Primary Prevention*: Public education campaigns, school education. *Secondary Prevention*: Screen individuals for signs of abuse. *Tertiary Prevention*: Refer patients to Alcoholics Anonymous or Narcotics Anonymous, promote coping and lifestyle changes.

*Homelessness*: - *Fast Growing Segment*: *Families with children - *Risk Factors*: Unemployment, migrant workers, veterans, metal illness, substance abuse, HIV/AIDs, at-risk youth. - *Key Health Issues*: Tuberculosis, infestations (scabies/lice), substance abuse, HIV/AIDS, mental illness. - *Key Health Issues of Veterans*: Mental health issues (PTSD, depression), substance abuse, suicide, traumatic brain injury, spinal cord injury, amputations.

*Key Health Risks*: Tuberculosis, dental disease, skin cancer, diabetes, obesity, high risk of suicide, increased work-related injuries (exposure to pesticides, injuries from machinery). - *Primary Prevention*: Education on reducing exposure to pesticides, accident prevention. Preventative care (immunizations, dental care). *Secondary prevention*: Screen for skin cancer, pesticide exposure, communicable disease. * Tertiary Prevention*: provide ER or primary care services, including treatment of symptoms of pesticide exposure.

*Airborne*: chickenpox, measles, tuberculosis, pertussis, influenza. *Foodborne*: salmonella, hepatitis A (fecal-oral route), E-coli, botulism. *Waterborne*: cholera, typhoid fever. *Vector-borne*: (i.e. mosquito or tick) lyme disease, malaria, Rocky Mountain spotted fever. *Sexually Transmitted*: HIV, Hepatitis B/C/D, syphillis, HPV, gonorrhea.

*Herd Immunity*: Most community members have immunity, protecting those who can't (or choose not to get) immunized. Make exposure unlikely. *Active Natural Immunity*: Body produces antibodies in response to exposure to live pathogen. *Active Artificial Immunity*: Body produces antibodies in response to vaccine. *Passive Natural Immunity*: Antibodies are passed from the mom to her baby through the placenta or breast milk. *Passive Artificial Immunity*: Immunoglobins are administered to an individual after they have been exposed to pathogen.

Communicable disease report is mandated by state and local regulations. State notification to CDC is voluntary. *Primary Prevention*: Provides education regarding immunizations, hand hygiene, proper food handling, risk of infectious disease when traveling to other countries (including Hepatitis A). *Secondary Prevention*: Provide screening, quarantine patients when needed, refer suspected cases for definitive diagnosis. *Tertiary Prevention*: Monitor treatment compliance (may require direct observation therapy).

*Lyme Disease*: Key symptom is red bullseye ring around the area of the tick bite. *Meningococcal Disease*: Individuals should get vaccinated prior to living in a crowded housing environment (college dorms, prisons, military housing). *Pertussis*: Children with pertussis should stay home from school until coughing is gone. Family members and those exposed should be treated with antimicrobials. Check immunization status of other children in school. *Tuberculosis*: Treated with up to 4 antibiotics (to prevent drug resistance) for 6-12 months. Family members need to be tested for TB. Sputum samples will be needed every 2-4 weeks -- patients are no longer infectious after three negative sputum cultures. Patients with active TB need to wear an N95 mask in public.

*Disaster Prevention*: Surveillance, inspections, immunizations, education, risk assessment. *Disaster Preparedness*: Create disaster action plan, identify evacuation routes, create disaster kit, identify meeting place and communication plan, *perform disaster drills*. *Disaster Response*: Assess extent of disaster. Perform triage, and direct those affected. Coordinate evacuations, quarantines. *Disaster Recovery*: Begins when danger no longer exists. Coordinate care in shelters and homes.

*Category A*: smallpox, botulism, anthrax, plague *Category B*: typhus, cholera *Category C*: hantavirus *Inhaled Anthrax*: Symptoms include sever dyspnea, fever, shock, muscle aches. Interventions include IV ciprofloxacin for those exposed (or have a high risk of exposure). *Smallpox*: Symptoms include *rash (begins on face and spreads down), high fever, headache, vomiting. Prevention includes vaccination.

*Consultation*: Request from provider to another physician or resource who can provide expert advice and/or services for the patient. *referral*: Provider requests or recommends management of one or more of the patient's concerns or issues to another provider or for support services (ex. support groups, churches, transportation services, meal delivery services).

- Help the patient transition from acute to community-based care. - Evaluate patient's medical needs, psychosocial issues, financial constraints. - Collaborate with patient, family, insurance companies, health care providers, medical service/equipment providers to meet the health care needs of the patient. - Facilitate discussion of patient's needs with an interprofessional team. - Provides referrals as needed.

*Informatics*: Incorporates nursing, information technology, and communication technology to develop and to support nursing practice and improve patient outcomes. *Telehealth*: Delivery of health care through technology (vs. in person). This is particularly helpful in rural areas, where there is a lack of specialty care services. *Nursing Roles in Health Policy*: Nurses can act as an *advocate* for changes in health policy, lobby legislators, serve in public office, or help from coalitions (collaboration of groups to achieve a goal).