NR 509 Week 1 Discussion: Social Determinants of Health

Sample Answer for NR 509 Week 1 Discussion: Social Determinants of Health

There are many factors that can affect an individual’s economic stability as related to NR 509 Week 1 Discussion: Social Determinants of Health. When assessing the patients’ health history two aspects that could be influenced by economic status would be their current and past medical history and their functional abilities. Studies have shown that individuals living with a disability are often faced with higher rates of unemployment and greater job insecurity with lower levels of pay (Shuey & Wilson, 2019). It is important to assess if a patient has a chronic disease, mental health disorder, intellectual disability, and any functional disabilities that could hinder them from employment opportunities. Economic instability can contribute to mental health issues such as depression and anxiety, which further impact physical well-being. If a patient does not have healthcare coverage it does not allow them to seek medical attention when needed. Living in poverty can negatively affect the health of children causing chronic stress and can affect a child’s psychological functioning (Hardy, Hill & Romich, 2019). Children living in these stressful environments have been shown to have more behavioral issues compared to those in a stable home environment. Clients living in economic instability are at greater risk of developing type two diabetes with associated complications. This is due to the inability to purchase healthy food options. Without a stable income, housing, and healthcare access individuals are at risk for further health complications, so clinicians need to assess the client’s current health status. It is a clinician’s duty to gather as much information about the patients’ health history and how their everyday living might affect their overall health. Understanding the client’s economic status allows clinicians to provide the proper resources to them to achieve optimal levels of health.

NR 509 Week 1 Discussion: Social Determinants of Health Resources

Hardy, B., Hill, H.D. and Romich, J. (2019), Strengthening Social Programs to Promote Economic Stability During Childhood. Soc Policy Rep, 32: 1-36. https://doi.org/10.1002/sop2.4

Shuey KM, Willson AE. Trajectories of Work Disability and Economic Insecurity Approaching Retirement. J Gerontol B Psychol Sci Soc Sci. 2019 Sep 15;74(7):1200-1210. doi: 10.1093/geronb/gbx096. PMID: 28977512; PMCID: PMC6748769

Sample Answer 2 for NR 509 Week 1 Discussion: Social Determinants of Health

As part of NR 509 Week 1 Discussion: Social Determinants of Health instructions, economic stability significantly influences a patient’s diet and nutrition. Access to nutritious food, food security, diet quality, nutrition education, and psychological factors are all intertwined with economic stability. Addressing socioeconomic disparities, promoting income equality, and implementing policies that ensure access to affordable, healthy food options are crucial for improving diet and nutrition outcomes, particularly among vulnerable populations. (French et al., 2019) Employment significantly influences an individual’s diet and nutrition through economic resources, access to healthy food, workplace environment, work-related stress, time constraints, and regular meal patterns. Promoting stable employment, workplace wellness initiatives, and supportive policies can improve individuals’ nutrition outcomes and positively impact their overall health and well-being.

Functional Abilities

A patient’s healthcare costs can be affected by their functional abilities through various factors as stated in the NR 509 Week 1 Discussion: Social Determinants of Health instructions. These include increased demand for specialized care, more frequent use of healthcare services, dependence on assistive devices, the necessity for long-term care, and the impact on employment and health insurance coverage. Addressing functional limitations through preventive measures, rehabilitation, and suitable assistive technologies makes it possible to manage healthcare costs better and enhance patient outcomes (High et al., 2019).

References:

French, S. A., Tangney, C. C., Crane, M. M., Wang, Y., & Appelhans, B. M. (2019). Nutrition quality of food purchases varies by household income: The shopper study. BMC Public Health, 19(1). https://doi.org/10.1186/s12889-019-6546-2Links to an external site.

High, K. P., Zieman, S., Gurwitz, J., Hill, C., Lai, J., Robinson, T., Schonberg, M., & Whitson, H. (2019). Use of functional assessment to define therapeutic goals and treatment. Journal of the American Geriatrics Society, 67(9), 1782–1790. https://doi.org/10.1111/jgs.15975Links to an external site.

NR 509 Week 1 Shadow Health History Assignment

Health History 

According to Bickley (2013) a clear, well organized clinical record is one of the most important adjuncts to patient care and gathering information using open-ended questions, then closed ended questions to prompt specific responses.  This paper provides an overview of clinical reasoning and the nurse’s decision making after providing a complete advanced health history and physical assessment. It will also give insight into the nursing process and how it may enhance clinical thinking, reasoning and judgement in the nursing practice. 

Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents for complete physical examination and evaluation for right foot injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview. Ms. Jones is alert and oriented, is seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene.  Her chief complaint, “I hurt my foot a couple of weeks ago and went to the ER. They said I should get a check-up . . . it’s been awhile since I’ve had one.” 

Ms. Jones reports that two weeks ago she tripped while walking on concrete stairs outside, twisting her right ankle and “scraping” the ball of her foot. She sought care in a local emergency department where she had x-rays that were negative; she was treated with tramadol for pain. She has been cleansing the site when she showers. She has been applying antibiotic ointment with a Band-Aid. She reports that ankle swelling and pain have resolved but that the bottom of the foot is increasingly painful. The pain is described as “throbbing” and “sharp, shooting” with weight bearing. She states her ankle “ached” but is resolved. Pain is rated 5 to 6 out of 10 after a recent dose of tramadol. Pain is rated 9 with weight bearing. She feels she “cannot walk on it.” She reports that over the past two days the ball of the foot has become swollen and increasingly red; yesterday she noted some “blood and pus” oozing from the wound, requiring her to apply a bandage. She denies any odor from the wound. Her shoes feel tight. She has been wearing slip-ons. She reports subjective fevers over the past two days with an episode “just the other day I felt feverish, hot and cold.” She denies recent illness. Reports a 20-pound, unintentional weight loss over past month and increased appetite. Denies change in diet or level of activity. Her medications include, • Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (cramps) • Tramadol 50 mg PO BID prn (foot pain) • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (Wheezing: “when around cats,” last use three days ago). Her allergies include, • Penicillin: rash • Denies food and latex allergies • Cats: sneezing, itchy eyes, wheezing. 

Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around cats. She rarely uses her inhaler. She was exposed to cats a few days ago and had to use her inhaler once. She was last hospitalized for asthma in high school but never intubated. Type 2 diabetes, diagnosed at age 24. She used to take metformin, but she stopped taking it three years ago, stating that the pills made her gassy and “it felt like I was taking pills and checking my sugar all the time, it was a pain to get refills so I just stopped.” She doesn’t monitor her blood sugar. Last blood glucose was elevated at the hospital. Denies ever having any surgeries. Menarche started at the age of 11. First sexual encounter at age 18, sex with men, identifies as heterosexual and never pregnant. Last menstrual period 6 weeks ago. For the past year cycles irregular (every 4-8 weeks) with heavy bleeding lasting 9-10 days. No current partner. Used oral contraceptives in the past. When sexually active, reports she did not use condoms. Never tested for HIV/AIDS. No history of STIs or STI symptoms. Last tested for STIs at age 22. She denies bleeding, bruising, blood transfusions and history of blood clots. 

Last Pap smear more than 4 years ago. Last eye exam in childhood. Last dental exam “a few years ago.” PPD (negative) ~2 years ago. She states that she does not exercise. Her  24-hour Diet Recall is that she skipped breakfast yesterday, and would typically have toast for breakfast, a sub sandwich for lunch, and a meatloaf or chicken with soup for dinner. Her snacks consist of pretzels and granola bars. Immunizations are, Tetanus booster was received two weeks ago in emergency department, influenza is not current, and human papillomavirus has not been received. She reports that she believes she is up to date on childhood vaccines and received the meningococcal vaccine in college.  Family has a smoke detectors in the home, wears seatbelt in car, and does not ride a bike. Does not use sunscreen. Guns, having belonged to her dad, are in the home, locked in parent’s room.  

Ms. Jones family history: 

• Mother: age 50, hypertension, elevated cholesterol • Father: deceased in car accident one year ago at age 62, hypertension, high cholesterol, and type 2 diabetes • Brother (Michael, 25): overweight • Sister (Britney, 14): asthma • Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol • Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol • Paternal grandmother: still living, age 82, hypertension • Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes • Paternal uncle: alcoholism Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problems.

She never married, and no children. Lived independently since age 20, currently lives with mother and sister in a single family home to support family after death of father one year ago, and anticipates moving out in a few months. Employed 32 hours per week as a supervisor at Mid-American Copy and Ship. She enjoys her work and was recently promoted to shift supervisor. She is a part-time student, in her last semester to earn a bachelor’s degree in accounting. She hopes to advance to an accounting position within her company. She has a car, cell phone, and computer. She receives basic health insurance from work, but is deterred from healthcare due to out-of-pocket costs. She enjoys spending time with friends, attending Bible study, volunteering in her church, and dancing. Tina is active in her church and describes a strong family and social support system. She reports stressors relating to the death of her father and balancing work and school demands, and finances. She states that “staying organized, trying to plan, and attending church” help her to cope. No tobacco. Occasional cannabis use from age 15 to age 21. Reports no use of cocaine, methamphetamines, and heroin. Uses alcohol when “out with friends, 2-3 times per month,” reports drinking “a few” drinks per episode. She drinks 4 caffeinated drinks per day (diet soda). She has not experienced foreign travel and does not have any pets. Not currently in an intimate relationship, ended a three-year serious monogamous relationship two years ago. She plans on getting married and having children someday. 

Complete Physical Assessment 

Head: Reports headaches that occur weekly with reading for the past few years. The headache lasts a few hours and is relieved with acetaminophen and sleep. Headaches are described as a “tight and throbbing feeling behind the eyes.” Denies head and neck trauma, brain cancer, migraines, seizures, dizziness, hair loss, and syncope.  

Ears: Denies difficulty hearing, tinnitus, ear pain, discharge, and loss of balance. Denies history of chronic otitis media and perforated tympanic membrane.  

Eyes: Complains of blurred vision associated with “reading and studying,” which has worsened over the past few years. No visual acuity testing since childhood. Does not wear corrective lenses. Reports eye redness and itching associated with exposure to cats. Denies discharge, pain, and diplopia. Denies glaucoma and congenital cataracts.  

Nose: Rhinitis and congestion related to cat allergy. Denies sinus problems, frequent colds/infections, and epistaxis.  

Throat, Mouth, Neck: Denies sore throat, dysphagia, and changes to voice quality. Denies dental pain or problems, oral lesions, and dry mouth, and changes in taste. Denies goiter, hyper/hypothyroidism 

Head: Normocephalic, atraumatic with no masses to palpation. Full distribution of hair on scalp, coarse hair noted on lateral face, chin, and upper lip. Eyebrows intact. Facial expression relaxed and symmetric without tics or drooping. No maxillary or frontal sinus tenderness. TMJ vertical and lateral movements smooth and symmetric. No clicking or crepitus.  

Ears: Normal shape without deformities, Darwin tubercle, redness or scaling. Auditory canals without edema or erythema. Tympanic membranes bilaterally pearly gray and intact with cone of light and bony landmarks visualized. No tenderness elicited when tragus palpated. No lesions noted. Hearing intact to whisper. Weber without lateralization. Rinne AC > BC bilaterally.  

Eyes: Skin free of redness, scaling or lesions. No entropion, ectropion, or edema noted. No pain elicited with palpation of the lacrimal gland, no discharge or pain noted with palpation of the lacrimal sac. PERRLA, anicteric sclera, conjunctiva pink and moist. EOMI, peripheral vision intact, 20/20 acuity left eye, 20/40 acuity right eye. Ophthalmologic examination reveals well-defined bilateral discs. Cotton wool spots and dot-and-blot hemorrhages scattered throughout right fundus. No lesions or exudates visualized in left fundus. No nicking, crossing changes, or papilledema seen bilaterally.  

Nose: Nose midline without deviation. Nasal mucosa pink, no exudates or polyps appreciated, inferior turbinates pink and moist. Frontal and maxillary sinuses not tender to palpation and percussion.  

Throat, Mouth, Neck: Oral mucosa pink, moist and intact. Uvula rises midline. Gag reflex intact. No dental caries. Velvety, hyperpigmentation noted circumferentially on distal neck near folds. Symmetric, midline without torticollis. Active range of motion – flexion, extension, rotation and lateral bending. Neck supple, without lymphadenopathy. Thyroid smooth and symmetric with no nodules or enlargement. No thyroid bruit. 

Respiratory 

History of poorly controlled asthma. Asthma diagnosed at age 2 1/2. Rarely uses inhaler. Uses albuterol inhaler when around cats. Was exposed to cats a few days ago and had to use inhaler once at that time. Last hospitalized for asthma in high school. Never intubated. Denies history of pneumonia, tuberculosis, and chronic bronchitis. Denies chest pain, dyspnea, current wheezing, hemoptysis, or recent cough.  

Respiratory rate: 22. Respirations easy and regular, able to speak in complete sentences. Skin without cyanosis. Normal trapezius muscle development. No scoliosis, kyphosis, pectus excavatum, or carinatum. Chest symmetric with equal expansion. AP < transverse diameter. Sternum midline without pectus excavatum or carinatum. Scapula equal and symmetric. Anterior and posterior chest wall is symmetric without lesions. Spine midline without kyphosis or scoliosis. Fremitus present and symmetric over all lobes. All lung fields resonant to percussion. Anterior lungs clear to auscultation, expiratory wheezes in posterior bilateral lower lobes. Absent bronchophony. O2 Sat 96% on room air. Bedside Spirometry: FVC 3.91 L; FEV1 3.15 L; FEV1/FVC Ratio: 80.56%. 

Cardiovascular 

Denies cough, chest pain, palpitations, dyspnea on exertion, orthopnea paroxysmal nocturnal dyspnea, peripheral edema, varicosities, and pain in lower extremities. Reports no blanching in fingertips when exposed to cold. Pulse 86. Blood pressure 176/84. No pulsations noted on inspection of chest and abdomen. S1 and S2, no murmurs, gallops, or rubs, regular rate and rhythm. No heaves, lifts, or thrills palpated over cardiac landmarks. Point of maximal impulse palpable at 5th intercostal space at midclavicular line. No jugular venous distention. Jugular venous pressure measured as 1 cm H20. Temporal and carotid pulses 2+, no thrill appreciated. Peripheral pulses 2+ throughout except right dorsalis pedis and posterior tibialis 1+ (obscured by local edema). 1+ edema noted on right lower leg. Capillary refill < 2 seconds on bilateral fingers and toes. 

Abdomen 

  She denies digestive problems, reflux, dysphagia, nausea, vomiting, diarrhea, constipation, changes in bowel habits, jaundice, abdominal pain, and bloody stools. Denies gallbladder and liver disease. Reports polyphagia, polydipsia, polyuria, and nocturia for past month. Reports unintentional weight loss of 20 lbs over the last 2 months. Usual diet consists of toast or smoothie for breakfast, sub sandwich at lunch, meatloaf or casserole for dinner, pretzels or granola for a snack. Eats fast food a “few times per week”, one serving vegetables per day. Caffeine: Denies coffee and tea, drinks 4 diet colas/day.  Denies flank pain, dysuria, urgency, and cloudy urine. Denies history of recurrent urinary tract infections and kidney stones. Denies vaginal discharge and vaginal itching. Menses irregular. No history of sexually transmitted infections and no pregnancies.  Protuberant abdomen with striae noted across lower quadrants. No pulsations or peristalsis noted on inspection. Abdomen soft, non-tender, and non-distended. Bowel sounds normoactive in all four quadrants. Tympanic to percussion in all quadrants. No masses or organomegaly palpated. Liver span percussed as 7 cm on midclavicular line, and palpated 1 cm below right costal margin. No masses, guarding, or rebound noted with deep palpation. 

Musculoskeletal 

Reports limited weight-bearing ability on injured foot. Right ankle sprain two weeks ago, now resolved. Patient reports persistent right ankle stiffness. Reports “crick in my neck.” Has experienced limping with recent injury. Denies history of fractures, gout, and arthritis. Denies myalgias and arthralgias. Denies back and neck pain and trauma. Denies generalized weakness. Does not exercise regularly. Muscle tone and bulk symmetric. No masses or deformities. No scoliosis, kyphosis, or lordosis. No cyanosis or pallor. No joint swelling. Full range of motion in all joints with 5/5 strength in cervical spine and all four extremities with exception of right ankle. Right ankle displays decreased range of motion and 4/5 strength. On plantar surface of the right foot an open wound is noted, it is inferior to the base of the first and second metatarsal. The wound is oval shaped and measures 2 cm x 1.5 cm, depth is 2.5 mm. Wound bed is beefy red with a whitish area at the center of the lesion, wound edges are irregular and appear white and moist. There is erythema surrounding the wound. There is a small amount of local edema. No drainage or odor appreciated. 

Neurological 

Headaches occur once a week behind the eyes with prolonged reading, resolved with acetaminophen and sleep. Denies fainting, dizziness, vertigo, weakness, syncope, numbness, tingling, tremors, seizures, and paralysis. Reports occasional clumsiness. Denies history of traumatic brain injury and meningitis. Denies recent changes in memory and mood changes.  Cerebellar functions intact as evidenced by smooth and coordinated rapid alternating movements in bilateral upper extremities, and coordinated finger-to-nose and heel-to-shin movements. Unable to assess gait and balance due to right foot injury. Sensation intact to light touch and accurate perception of sharp and dull touch in all four extremities. No sensation of monofilament on distal plantar surfaces bilaterally, sensation intact on heels. Stereognosis and graphesthesia intact bilaterally. Proprioception intact in upper and lower extremities. Deep tendon reflexes: 2+ bilateral biceps, brachioradialis, triceps, patellar and Achilles. 

Skin, Hair and Nails 

Reports acne since puberty and bumps on the back of her arms when her skin is dry. Complains of darkened skin on her neck and increase facial and body hair. She reports a few moles but no other hair or nail changes.  Skin is warm and dry with elastic turgor. Scattered comedones and pustules. Right ball of foot: 2 cm x 1.5 cm, 2.5 mm deep wound, red wound edges, no drainage. Hair is evenly distributed. No cyanosis or clubbing in nails. Capillary refill < 3 seconds. 

Psychological 

Reports recent grief and insomnia related to father’s death. Reports anxiety related to school tests and finances. Denies current depression, insomnia, change in mood, concentration or attention, and suicidal or homicidal ideation. Denies amnesia and dementia. Denies changes in remote or recent memory, and confusion. Reports no history of mental illness.  

Evidence Based Individualized Treatment Plan and Clinical Reasoning 

Diabetes 

Start metformin 850 mg PO QD, increase to BID in two weeks. Gassiness and bloating should improve in 4-8 weeks. Dispense 60 tabs. Recheck HbA1c in 6-8 weeks. If HbA1c goal < 7. Write a prescription for a glucometer and/or test strips. Take and record blood glucose readings daily upon waking and 2 hours after meals. Keep a food diary and try to keep each meal to 50g carbohydrates or less. Exercise at a moderate pace for 30 minutes every day once foot is healed. Monitor weight every 1-2 weeks. Weight loss goal 1-2 pounds/week. Goal BMI < 25 kg/m2.  Without proper education and good follow-up planning, as many as 30% of patients with diabetes are at risk for re-hospitalization within 30 days of discharge (Medscape, 2015). 

Asthma 

Use albuterol inhaler every four hours for cough, wheeze and shortness of breath for the next 2 days. If symptoms persist for longer than 2 days of consistent use of albuterol, please return to clinic for reevaluation. Peak flow reading is 70% of predicted. Develop asthma action plan.  Asthma is a disease of airway inflammation and airflow obstruction characterized by intermittent symptoms, including wheezing, chest tightness, shortness of breath and cough (Hammer & McPhee, 2015). 

Foot wound infection   

Start clindamycin 300 mg PO Q6 hours for 7 days. We would not want to use Septra DS due to her diagnosis of asthma and current wheezing. Change wound bandage twice/day. Use non-adherent bandage on the wound to keep the wound clean and moist. Refer to home health nurse for wound care. Wear aircast and crutches until reevaluation in 2 weeks. If symptoms worsen, consider referral to physical therapy. She needs to offload the wound and stabilize her ankle with the aircast. She should use the crutches as much as possible to promote healing. Refill tramadol 50 mg tabs, take 1-2 tabs PO every 4-6 hours prn, dispense 30 tabs. For mild pain, take ibuprofen 800 mg PO every 6 hours prn. Counsel on signs and symptoms of DVT, such as new onset unilateral calf pain and shortness of breath.  

 Hypertension  

Recheck blood pressure in 1 month.   Assess weight loss, management of diabetes, fatique, continue follow-up referrals. Patient education and motivational interviewing should be discussed at all follow-up visits. If Tina is not taking medications, her mutually agreed upon treatment plan should be modified.  

 Check CBC, blood pressure, RTC for Pap smear in 1 month.  RTC in 1 week to reevaluate wound, refer her to podiatry to establish care and to ophthalmology for diabetic retinopathy. 

Developmentally and Culturally Specific Assessment and Plan of Care 

This is a developmentally alert and oriented 28 year old educated African American woman able to comprehend information  and instructions well, she will be encouraged to follow-up with a primary physician, monitor her blood sugar, maintain a diabetic diet, continue visits with an endocrinologist, assess further weight loss, and report signs and symptoms of infection to foot .  

Conclusion 

             The ultimate goal for Ms. Jones is to provide her with the survival skills needed to manage and take responsibility for his or her own health. Optimal diabetes care requires that the patient have some understanding of the pathophysiology of the disease, is comfortable with glucose self-monitoring.  Patient education should include how to manage asthma, know what the triggers are, to minimize exposure to them, and take medications as prescribed by the healthcare provider.References 

Bickley, L. S. (2013). Bates guide to physical examination and history taking (11th ed.). Philidelphia, PA: Wolters Kluwer Health / Lippincott, Williams, & Wilkins. 

McPhee, S. J., & Hammer, G. D. (2014). Pathophysiology of disease: An introduction to clinical medicine (7th ed.). New York, NY: McGraw-Hill Medical. 

Medscape (2015). Treating Hyperglycemia and Diabetes With Insulin: Inpatient to Outpatient: Discharge Planninghttp://www.medscape.org/viewarticle/580217_6