Professional Standards in Nursing

V: Population Health Nursing

Varying population groups require special attention, care, and sensitivity to ensure that their needs are met. Health care disparities exist between different groups of people. Some of the vulnerable groups that are at risk for health disparities include minority groups, uninsured groups, the impoverished or homeless, refugees, immigrants, disabled people, those with chronic health problems, those who are incarcerated, those with limited English proficiency, and members of the LGBTQIA community. They experience greater risk factors, a lack of necessary access to care, and increased morbidity and mortality as compared with the general population.

• Nurses should be aware of the disparities that exist and plan to prevent them.
• Nurses should be self-aware and understand their own culture, values, beliefs, ethics, personality, and communication style. Recognizing all biases and being respectful to all people despite differences can influence satisfaction and quality of care.
• Nurses should know of the most prevalent diseases and infections for population groups.
• Initial health care visits and every visit thereafter need to be done with a nonjudgmental, nonthreatening approach. Populations have general similarities, but each patient is an individual, and stereotyping should be avoided.5
• Focus on the clients’ reported symptoms first. This encourages adherence and follow-up. Subsequent care should include health maintenance, attention to common problems and concerns, and establishing an emergency contact person, if available.

Chronic Health Problems and Common Infectious Diseases in the U.S.

The following include various risk factors, the most common of which include tobacco use, poor nutrition, obesity, lack of physical activity, and excessive alcohol use.

1. Heart disease
2. Cancer
3. Lung disease
4. Stroke
5. Alzheimer’s disease
6. Diabetes mellitus
7. Kidney disease

Common infectious diseases include STDs (chlamydia, syphilis, gonorrhea, genital herpes, human papilloma virus, human immunodeficiency virus, and acquired immunodeficiency syndrome), Influenza (the flue), Staphylococcus aureus, Escherichia coli (E. coli), Herpes simplex 1 and 2, Shigellosis, Norovirus, Salmonella, Pneumonia, and Hepatitis C. (John Hopkins, 2020)

Needs Assessment Tool

The following questions is a comprehensive list of all necessary (but not always) questions to produce a focused assessment. Utilize these general background questions to determine which further assessment questions are appropriate.

Initial: introduce yourself and describe your role; for example, “I would like to ask you some questions so that we have information about your individualized needs. Do I have your permission to ask you some questions?”

General Background Questions:

1. Orientation with client:
   • Are you comfortable talking with me?
   • What name would you like for us to address you with?
   • What is your primary language spoken?; Do you speak and understand English?; In which language do you communicate?; Do you need an interpreter?
   • Do you feel you are able to adequately answer questions regarding your health?
   • What is your age?
   • Is there a specific gender you identify with?
   • What is your ethnicity?
2. Client lifestyle:
   • Do you have any cultural, religious, or spiritual preferences you would like us to consider in your plan of care?
   • Do you have any dietary preferences that you would like us to include in your plan of care? Describe your eating patterns in a 24-hour period.
   • Do you exercise? What do you do and how often?
3. Client health habits:
   • Do you use any remedies when you are sick?
   • What do you do when you are sick?
4. Client socioeconomic status:
   • What is your living situation? Where do you live? Who do you live with? Do you have children?
   • Do you have a support system?
   • Would you like to name a support person or emergency contact person?
   • Do you have access to financial resources needed to live?
   • Do you have health insurance?
5. Personal and medical history:
   • Do you feel safe at home or where you live? Have you been abused within the last 12 months? Do you encounter crime or violence in your life? Is anyone hurting you, physically or emotionally in any other way? Have you ever been or are you now being bullied?
   • Do you smoke, drink alcohol, or use any type of drug?
   • Do you have or need a health care proxy?
   • Do you have an advance directive? If not, would you like more information about this?
   • When was the last time you sought health care? For what reason?
   • Do you have any fears about seeing your provider?
   • Do you currently or have you ever had an infectious disease?
   • Have you been exposed to anyone with an infectious disease?
   • Have you been exposed to anyone with an infectious disease? If so, how was this exposure treated?
   • Have you ever been tested for COVID-19? Or tested for immunity?
   • Have you had the recommended COVID vaccines?
   • Have you traveled outside of the country recently?
   • Are you up to date on immunizations?
   • When was your last influenza vaccine?
   • Have you ever been vaccinated for pneumonia? If so, when?
   • Do you have a history of mental health problems?
   • Have you ever had feelings of committing suicide? If so, do you have these feelings now? Do you have a plan?
   • Are you a veteran or a member of the military?
   • Do you have any chronic illness, disability, or other past medical history?
   • Have you ever been incarcerated?
   • Are you an immigrant or refugee?
6. Further Questions based on Living Situation:
   • Do you have a home? Do you live alone? Whom do you live with at home?
   • Do you drink alcohol? Any other type of drug use?
   • Have you been exposed to environmental irritants?
   • Have you had problems with asthma, anemia, lead exposure, ear infections, gastrointestinal illness, or mental health?
   • Are you willing to follow-up on your health care recommendations if given the necessary resources?
7. Further Questions based on Health Insurance Coverage:
   • What health insurance do you have?
   • Do you have the financial means to pay for your health care?
   • Are you willing to work with a social worker to seek health coverage?
8. Further Questions based on Financial Status and Access to Resources:
   • What is your education level?
   • What is your income?
   • Do you have family you are in contact with?
   • Is anyone in your immediate family disabled?
   • Do you have a support system?
   • Do you live in a safe community?
   • Do you seek health care on a routine basis?
   • Are you willing to work with a social worker to increase your access to community resources?
9. Further Questions related to Abuse:
   • Do you have or have you had any bruises, sprains, broken bones, fatigue, shortness of breath, muscle tension, involuntary shaking, changes in eating or sleeping, sexual dysfunction, or fertility problems?
   • Do you experience nightmares, anxiety, uncontrollable thoughts, depression, or low self-esteem?
   • Do you have anxiety or depression? Do you have thoughts of harming yourself or others? If so, do you have a plan?
   • Do you ever feel hopeless, worthless, apprehensive, discouraged? Do you lack motivation or faith? have you questioned your trust in others?
   • For a child: Do you have any problems at school? Are you being bullied?
10. Further Questions based on Gender and Sexual Orientation:
    • Can you describe your gender identity and sexual orientation preferences?
    • Which pronoun would you like us to use for you (he, she, they, other)?
    • Do you seek regular and routine health care? When were you last seen?
    • When was your last breast exam, mammogram, Pap smear, testicular exam, prostate exam?
    • Do you perform breast or testicular self-examination?
    • Do you have any past medical history?
    • Are you sexually active? If so, how many partners do you have? Do you employ safe sex practices?
    • Do you smoke, drink alcohol, or use any other type of drug?
    • Do you have any problems with depression or anxiety? Do you have thoughts of harming yourself or others? If so, do you have a plan?
    • Do you take hormone therapy?
    • Are you up to date on your immunizations?
    • Do you have children? If not, do you wish to or plan on having children?
    • Do you feel you have access to necessary resources such as health care or other benefits?
11. Further Questions related to Mental Health:
    • Do you seek routine health care?
    • Describe your eating habits in a 24-hour period.
    • Describe your activity level.
    • Do you have any past medical history?
    • Do you take any medications? If so, what are they and do you experience and side effects?
    • Do you smoke, drink, or use any other type of drug?
    • Do you experience depression or anxiety? Do you have thoughts of harming yourself or others? If so, do you have a plan?
    • What do you do to cope with stressful situations? Do these coping strategies help you?
    • Do you have a support person in your life?
    • Are you sexually active? If so, do you employ safe sex practices? How many partners do you hav?
12. Further Questions related to Veteran/Military Status:
    • Do you have any problems with mental health, such as post-traumatic stress disorder, moral injury?
    • Have you had any traumatic brain injuries?
    • Have you had any other injuries?
    • Describe your living situation.
    • Are you interested in any community support group?
13. Further Questions related to Incarceration:
    • Have you ever been a victim of abuse or rape?
    • Do you have any past medical history, particularly asthma, diabetes mellitus, hypertension, heart disease, mental health problems, or communicable diseases?
14. Further Questions related to Immigration:
    • Do you have problems with mental health?
    • Are you able to speak and understand English?
    • Do you have access to resources such as housing, transportation, health care, and educational services?
    • Do you have any past medical history, such as accidents, injuries, hypothermia, gastrointestinal illness, heart problems, pregnancy complications, diabetes, hypertension, malnutrition, or infectious or communicable disease?
15. Further Questions related to Chronic Illness:
    • Do you have access to a primary health care provider?
    • Do you see a primary health care provider or specialist on a regular basis?
    • Are you able to follow up on the recommendations made by your primary health care provider and/or specialist?
16. Summary: is there anything else you would like to share regarding your ability to maintain your health or any other issue or concern?

COVID-19

The COVID-19 pandemic is a serious global health pandemic and is a major public health concern. It has caused severe illness and even death in some individuals. COVID-19 may be more easily contracted by the elderly; those with a chronic health condition e.g. diabetes or respiratory or cardiac disease; those who have cancer; those who are immunocompromised e.g. from chemotherapy or disease; and minority groups. (John Hopkins COVID-19 racial disparities). Other populations affected are those living in crowded conditions or are institutionalized. It is considered a respiratory illness that is caused by a virus called SARS-CoV, although the illness is respiratory in nature, the virus also attacks and affects many different body systems.

• Symptoms: cough, shortness of breath, respiratory congestion, fever, muscle pain, sore throat, loss of taste and/or smell; additionally body aches, fatigue, runny nose, and gastrointestinal symptoms (nausea, vomiting, diarrhea). Other manifestations may occur.
• Danger Signs that indicate immediate need for emergency care: difficulty breathing, persistent pain or pressure in the chest, new confusion, inability to wake or stay awake, bluish lips or face (cyanosis)
• When admitted with the suspicion of COVID-19, controlling the spread of the disease is a primary concern. The nurse institutes safety measures for protecting and preventing that client from contracting the illness. Be an advocate for educating the public about the measures to prevent its spread. These include hand washing, eye protection, the use of a mask, physical distancing, avoiding crowded situations, avoiding close contact with people whoa re sick, covering the nose and mouth when coughing or sneezing, keeping the hands away from the eyes and face, and self-quarantine.

Minority Groups

Some individuals in these groups may be less likely to have health insurance coverage or a regular source of health care. (Center for American Progress: Health disparities by race and ethnicity).

• Obesity, diabetes mellitus, end-stage renal disease secondary to diabetes, and cervical cancer are more common among the Hispanic American/Latinx population.
• The Native Hawaiians and other Pacific Islanders population is noted to have higher rates of smoking, alcohol consumption, obesity, and diabetes mellitus. Hepatitis B, human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), and tuberculosis are more frequent diseases. Noted is that there is a high incidence of infant mortality and sudden infant death syndrome (SIDS) in this population.
• In the Native American and Alaska Native populations, geographic isolation and income may be factors with regard to receiving health care. Inadequate water supply and sewage disposal can be a factor with infectious diseases. Smoking and the use of alcohol are more common, and diabetes mellitus, cancer, stroke, heart disease, and accidents are a concern. Additional concerns include mental health alterations, suicide, infant mortality, sudden infant death syndrome (SIDS), teenage pregnancy, liver disease, and hepatitis.
• Obesity, diabetes mellitus, hypertension, heart disease, asthma, and cancer occur more commonly among African Americans, with leading causes of death being heart disease, cancer, and stroke.
• Cancer, tuberculosis, and hepatitis are more common health problems of Asian Americans, with leading causes of death being cancer, heart disease, and stroke.

Health care considerations:

1. Cultural responsiveness is critical to reduce disparity. This can help improve health outcomes and quality of care.
2. The nurse and other health care professionals need to be aware of health care variations and risk factors for various populations in order to facilitate appropriate care and access to needed health care services.
3. It is important for the nurse to examine their own values to be responsive to the needs of someone from another population group; awareness is a useful tool in caring for others.
4. Language barriers influence access to health care. It is important to remember than family and friends should not be asked to be interpreters for confidentiality, potential conflicts of interest, and risk of miscommunication. Designated interpreters by the institution should be called upon.
5. Lack of access to preventive care needs to be addressed.
6. Important health education topics include preventive lifestyle practices: diet, meal planning, exercise, and other lifestyle changes that reduce the risk for diseases, including infectious and communicable diseases.
7. Return explanation and return demonstration are of particular important to ensure safety and mutual understanding.

Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual Individuals

This group represents a wide range of varying characteristics. They are collectively referred to as “LGBTQIA”. Among healthcare professionals, there is often a lack of awareness about the specific needs of this population.

• Fears of stigmatization and being viewed as different can reduce willingness to approach health care providers.
• Transgender individuals may be less likely than other groups to have certain screenings done, e.g., a prostate exam for a transgender woman, or a mammogram for a transgender man. (GLAAD Media Reference Guide: Transgender)
• Sexually transmitted diseases are of concern for this population.
• Breast cancer and cervical cancer are a concern, likely because of reduced screenings and nulliparity.
• Depression and suicide are concerns.
• Rejection from friends, family members, and social support systems may be a stressor. Teenage members of this population are more likely to be threatened, bullied, injured, raped, and victimized. For these reasons, school absenteeism can be a problem. Youth in this population is at heightened risk for abuse by family members due to their sexual orientation.
• This population may also experience struggle with child-rearing due to the expenses of adoption, artificial insemination, and surrogacy. They may also fail to quality for certain benefits, e.g. spousal death benefits, and are less likely to have family members who assist them in elderly or disability care.

Health care considerations:

1. Create a welcoming, nonjudgmental environment when caring for this population. Using their preferred pronouns allow for developing and maintaining rapport. Measures such as altering signage in gender identification in forms can better serve the health needs of this population. Treat the patient according to their identity while also maintaining an understanding of their risk factors based on biological drivers of health.
2. Health promotion measures focuses on screening for health concerns such as cancer, STIs, depression, and suicide; and health education particularly for safe sex practices.
3. A careful sexual history and appropriate counselling is important for all members of this population.
4. Nonocuppational postexposure prophylaxis (nPEP) or prophylactic antiretrovirals should be considered for those with potential for HIV.
5. Hormone therapy needs to be monitored at regular intervals; associated complications, such as polycythemia occurring with exogenous testosterone use, need to be detected and treated early.
6. Biological and reassigned gender-based preventive screenings should still be continued for those who have underwent sexual reassignment; e.g. transgender men over the age of 50 should continue to have regular breast cancer screening by way of mammography, with the new presence of breast tissue. However transgender women should also undergo screening due to the risk of residual breast tissue forming cancer.

Homeless Individuals

All backgrounds and family units can be affected by homelessness. There is a risk for early death related to health problems. Disability often results from illness and becomes a barrier to employment, which further augments the problem of homelessness.

• Infants affected by homelessness often have low birth weights and are more likely to die during infancy (12 months).
• Children affected by homelessness are sick more often with illnesses such as asthma, iron deficiency, lead poisoning, ear infections, gastrointestinal illness, and behavioral and mental health problems. They may begin to act out or become less attentive in the classroom when needs are not met. Risk-taking behaviors like alcohol and drug abuse become more common, as with depression and suicide. Unintended pregnancies and STIs are a concern. Physical and sexual abuse is also a concern.
• Homeless individuals can be met through avenues such as outreach programs. Initial health care visits should be done with a nonjudgmental, nonthreatening approach. Focus on reported symptoms to encourage adherence and follow-up. They may not adhere to medical treatment recommendations and therefore should require close follow-up as much as possible. Medications with risk for abuse and addiction should be avoided. Subsequent care should focus on health maintenance, attention to common problems and concerns, and establishing an emergency contact person if available.

Homeless individuals experience limited access to health care, problems with food, difficulty with safety, violence, stress, unsanitary living conditions, extreme exposure to weather. This leads to health problems including:

1. Dental problems
2. Malnutrition
3. STIs including HIV and AIDS
4. Lung diseases, including bronchitis, tuberculosis, and pneumonia.
5. Infectious and communicable diseases.
6. Mental health problems
7. Substance abuse problems
8. Wounds and skin infections

Socioeconomically Disadvantaged Individuals and Families