Epidemiology HIV PPT , brem, ross, tenn new
Beverly Tennant
Clinical Reflection
The hospital of choice for my clinical experience is Kings County which is located in East Flatbush, a culturally and linguistically diverse community. My experience at Kings County Adult Health Clinic was very informative and challenging. It forces me to think critically and analytically, to be knowledgeable about the health topics that are discussed in the clinic each week with members of the community. This course expands my knowledge as a nurse, and provides valuable experience that I needed to meet the needs of the people in this diverse community. In the clinic I focused on health promotion, disease prevention, and health maintenance, which is at the heart of community-based nursing. I will now discuss how I accomplish my clinical objectives.
1. Objective #1: Demonstrates individual professionalism through personal behaviors and appearance.
I demonstrate professionalism by dressing appropriately for clinical, and behaving in a professional manner. I maintain an atmosphere of friendliness and professionalism by been courteous, friendly, and respectful to my patients, my clinical instructor, and the staff at Kings County Hospital. I also had to demonstrate sensitivity to my patient’s cultural, religious differences, and needs. I maintain patient’s confidentiality by not discussing patient information with other patients, staff, or in the elevator with my classmates. I also kept patient personal information in printed form or on the computer from the views of other patient’s and talk privately with them regarding their personal health issues. I would read thoroughly and seek clarity on different health topics to gain knowledge before I present it in the clinic. I also complete my presentations or group teachings within the allotted time frame, allowing time for questions, and feedback from the patients in the clinic. I complete all assigned duties in a timely manner, to facilitate the flow of care in the clinic. I was able to ask the supervisors in the clinic questions about the organization policies and procedures, and where to allocate the things that I need to carry out my duties effectively. I attended clinical conferences and was able to listen to the nurses give report and collaborate with other multidisciplinary teams, regarding patient care. I also attended clinical on time and had not missed any clinical sessions, in accordance with school policy.
2. Objective # 2: Employ analytical reasoning and critical thinking skills when providing care to individuals and families in the community setting.
I employ analytical reasoning and critical thinking skills when providing care to individuals and families in the clinic, by interviewing the patient and accessing patient medical records to collect information. I also assess the impact that the patient religious belief and cultural belief has on his/her health. I realized that many of patients who attend the clinic are from the West Indies; African, Hispanics, and Haitian culture that share a strong belief in the use of herbal home remedies and vitamin supplements to maintain their health. One example is the belief that eating garlic and drinking fresh juices can reduce the blood pressure. During my clinical rotation I have to assess for any herbal remedies that the client used daily with regular medication. For example, a client who takes a garlic tablet and is taking Coumadin have be taught that he/she cannot use garlic, while on Coumadin. I have to focus my teaching on diet modification and eating habits, since members of this community like to eat fried, fatty, starchy foods in large portions. Many of the patients I serve are adults in the middle-age to late adult stage, and might be experiencing physical changes such as hearing loss and poor eyesight, so I had to assess for these changes and modify my teaching accordingly. I was allowed to assist the staff nurse to perform complete physical assessments for patients who were coming to the clinic for the first time. I also had to prioritize care according to the severity of the patient illness, vitals or glucose measurements. Base on assessments, I had to implement safe, appropriate care for my patients and evaluate the outcome. In clinical, I was not allowed to dispense medications, but I had the opportunity to evaluate patient response to treatment, such as monitoring blood pressure, oxygen saturation, respiration, and measuring glucose after treatment. I then report and document my findings report to the primary nurse. I educate the patient regarding the dosage, frequency, and possible side effects of the medication that were prescribed and assess the patients understanding of what was taught. I also utilized patient safety, by washing my hands before and after care to prevent the spread of infection to the patients, make sure examination beds are locked and are in the lowest position. I assess for the risk of patient falling, the safety of patient getting in and out of wheelchair, and encourage them to lock their chair before getting in or out. I utilize the two patient identifier used at Kings County Hospital to identify each of the patients, such as the patient name, MAR number, and date of birth. I also check the environment for safety hazards, such as water spills and alert housekeeping staff. I try to maintain a clean, safe, secure, and comfortable environment at all times.
3. Objective #3: Effectively communicate with diverse groups and disciplines using a variety of strategies regarding the health needs of individuals and families in the community setting.
I effectively communicate with diverse groups and disciplines using a variety of strategies regarding the health needs of individuals and family in the clinic. I utilize therapeutic communication skills with patients and their families by explaining in a timely manner the name and reason for each test, the vital signs readings, and when a family is anxious or upset, I exercise active listening. I also communicate using words and terms that the patient understands. I clearly and effectively communicate with my instructor and the staff members at Kings County Hospital by reporting specific data or findings to them. I document and report any assessment findings and intervention with the responsible nursing staff. For example, for a patient that presents with low glucose level, I would give orange juice or a light snack and assess the glucose level after an hour and document and report the result.
4. Objective #4: Establish environment conducive to learning and use a plan for learners based on evidence-based practice.
I develop and implement teaching plans for the adult patient and family, by firstly assessing how best the patient learn, in order to tailor my teaching to meet the patient needs. Some patients learn best by reading, doing hands on or listening. I used pictures, demonstration, and at times ask the patient to teach back what was learned. During my teaching presentation, I encourage a quiet environment, with no cell phone use. I also get our patients to actively participate by asking questions and having a quiz in the end to evaluate how well they listen. I also evaluate how well the patient and family learn what is being taught by having them demonstrate or teach back to me what they learned.
5. Objective # 5: Utilize informational technology when managing individual and families in the community.
During my clinical experience I use informational technology when managing individuals and families in the community by using the computer or cell phone to access information from the internet about a particular treatment or medication for the patient. At Kings County, I was also able access handout and patient teaching information for medication from Micro Medixs. I also main strict confidentiality with client records by not leaving patient files hanging around or leaving it exposed to other patients. I discuss lab results and other findings privately with the patient or family. I always log off the computer completely and keep my password private in order to prevent unauthorized access to patient information. For patients that require a language translator or interpreter, I used Cyracom to access a language interpreter in the patient’s native language. This always help the patient to express their needs better and help to improve care, especially when I understand what the patient needs are.
5. Objective #6: Demonstrate a commitment to professional development.
I researched my teaching topics to make sure I am giving up-to-date information to my patients. I also read nursing magazines and other healthcare articles to maintain current knowledge and competency in nursing practice so that I can provide the best evidence based care for my patients. I am currently pursuing my BSN degree, which has equipped me to take on leadership roles in the community, to serve as a mentor or to act as a role model for other community health nurses. I took several continuing education classes to expand my knowledge base in nursing, classes such as leadership, how to work with difficult people, bullying , medication error, and documentation. I hope to continue to pursue my master’s degree in either Nursing Administration or to become a Nurse Practitioner. There is one area that I wish I had gained more experience in and that is Medical Surgical Nursing. However, I keep abreast of new medications and advances in Medical Surgical Nursing by reading nursing magazines, visiting nursing websites, and talking with friends and colleagues who worked in Medical Surgical Nursing area. I evaluating myself, I need to be more educated in the area of emergency, disaster planning, and bioterrorism to be better able to help people in the community in case of emergency. Community health nursing is very challenging in the sense that I was face with many problems in the community and I had to find effective ways to deal with them on my own, such as safety and family conflict regarding patient care. However, I am committed to learn and to adjust to meet the challenges of independent practice in community healthcare. Each day I faced a new challenge, but I have learned to think critically, to consult or collaborate with others, and this has created great learning experiences. I have become better at critical thinking and problem solving to meet my patients needs.
7. Objective #7: Incorporate professional nursing standards and accountability into practice.
I practice within the scope of my duties, by assessing, planning, implementing, directing, supervising, evaluating direct and indirect nursing care, and identifying outcomes for patients in the community healthcare setting. I also provide health education, evaluate nursing intervention, and offer emotional support to my patients. I record and report patient information to ensure continuity in the provision and coordination of patient care, and collaborate with other heath-care professionals, by reporting any changes in vitals etc. I also take responsibility for my action in the clinical area, by reporting to the responsible staff and by educating patients appropriately regarding their health issues. For example, a patient who on assessment for sexual risk was found to have had multiple sexual partners, and was not wearing condoms consistently, he was informed in an honest way of the risk he was taking for contracting HIV and STD. I also performed my duties in accordance with Kings County’s vision of striving to provide the highest quality healthcare service, with an emphasis on patient safety, in a customer-centered environment. I also embrace the mission statement of the organization by recognizing that every patient and every employee has great value , so in showing respect for the patients, including their right to privacy, and confidentiality, I was honoring the organization first and highest value of respect.
8. Objective #8: Collaborate with clients, significant support persons and members of the health care team.
During my clinical duties I had to collaborate with patient and their families, especially when teaching about diet, medication, and appointments. If a client was not able to read or understand English well, in addition to using a Cyracom interpreter to interpret for the patient in the their native language, I also teach the family member to ensure continuity of care, in the event that the patient forget what was taught. I assisted with coordinating patient care with other clinics within the organization, such as making appointments for gynecology, dental, or podiatry clinics. I gave patient written information and encouraged them to have a yearly mammogram, PAP smear test, and eye exams. Patient who reported to me that they are having financial problems and cannot afford to buy medications or pay for their clinic visit were referred to apply medical assistance through the hospital, wherewith the patient would only pay twenty dollars for the clinic visit and were able to fill their prescriptions at the hospital pharmacy for a small fee. I refer patients with disability to social services for assistance with food stamps or transport assistance. I was able to assist patients to make calls to access a ride to inform them that they are ready for pick up.
9. Objective #9: Recognize the impact of economic, political, social and demographic forces that affect the delivery of health care services.
Kings County Hospital is located in East Flatbush area, which is composed of Blacks (74%), Whites (9%), Hispanics (9%), and Asians (2%). The leading health problems in this area are STI, obesity, hypertension, diabetes, and mental health. The clinic is always very crowed, with limited staffing, the waiting time for treatment can be very long and tedious. There is little time for the nurses to teach patient about their care and after a long wait many patients are just eager to leave. Some patients will even leave before getting the care that they need, because of the long wait. As a community health nurse, I have to advocate for our senate representatives to continue to keep hospitals in the area open, to prevent overcrowding in one hospital, and to give patients options as to where they can access care. I can also advocate for more staffing, which has been proven to increase health outcome for the patient. I had personally signed a letter that was sent out via email to nurses by NYSNA, encouraging our senate representatives and governor to keep Kingsboro psychiatric Center and Long Island Hospital open. This resulted in our senators, House of Representatives, government officials/agencies, and NYSNA getting these organizations to remain in business. As a community health nurse I can teach my patients and encourage them to make changes in diet and sexual practices to improve their health. I also have to make teaching materials simple, since many in this population are not able to read or speak English well. Since the clinic is located in a culturally and religiously diverse area, I have to take into account the patient’s culture and religion belief when providing care.
In conclusion, this clinical experience and my community health class has enable me to grow in a number of ways. I have learned to do an assessment of the community that I serve and see the needs of the community. It also enable me to see areas where services are needed and where I should focus my teaching. The community assessment assignment that I did in class provided me with the knowledge that I needed to do an assessment of this neighborhood. Through assessing the neighborhood, I was able to learn some of the health issues that affect several members of this community, such as heart disease, diabetes, hypertension, obesity, and sexual transmitted diseases. I was able to develop teaching plans to educate and address these issues with the patients in the clinic. I have learned quite a lot from my patients, who gladly passed on their rich knowledge and experiences of cooking, culture, and spirituality to me. Many of my patients have offered words of encouragements and often prayed for me to have good health and success in my career. I have not only learned to work independently and be an independent thinker, but I have also learned to collaborate with other team members to ensure continuity of care my patients. This course has changed my limited view of Community Health Nursing, such what Community Health Nurses do, their responsibilities, and the differences they make in the community. I have learned of the various settings in the community that community health nurses provide valuable services, areas such as a community health clinics, churches, homeless shelters, schools, homes, and organized events such as health fairs. This has taught me to that as a community heath nurse, I play an important role in helping to build the community that I serve, by educating and advocating for additional resources that the community needs, and promote awareness of the health needs of the community. This has been a great learning experience for me, one that gives me a better outlook of community Healthcare Nursing and better understanding about patients in the community that I serve.
Community Health Nursing
Physical Assessment Based on a Case Study
Erica Ross, Beverly Tennant, Greganne Bremner Case Study 5
Mr. Ruiz is a 42 year old male recently diagnosed with HIV/AIDS after being hospitalized with pneumonia. He lives with his 86 year old mother in a detached house that he owns in park slope/Brooklyn. He is an accountant and owns his own company. He has had unintentional weight loss of 35 pounds in the last 6 months. Mr. Ruiz mother is in early stage of Alzheimer disease. IDENTIFYING DATA 1. Name: Mr. Ruiz 2. Address: 234 15th street, Brooklyn, New York 11215 3. Age: 42 4. Date of birth: April 11, 1931 5. Birthplace: USA 6. Gender: Male 7. Marital Status: Single, in a relationship with girlfriend 5 years 8. Race: Hispanic 9. Religion and Spirituality: Catholic 10. Occupation: Accountant 11. Health Insurance: Blue Cross Bluesheilds 12. Source of history: Patient
CHIEF COMPLAINT (s) (CC): Weight loss, N/V, not eating much and not sleeping
Adult: Health history: 1. Illness (physical, mental and emotional): HIV/AIDs, Pneumonia, HTN, depressed. 2. Substance Use (Alcohol, Smoking, and Drug Abuse): no drug use, drinks alcohol occasionally. 3. Adverse Drug Reactions: none 4. Allergy: NKA to food or medication. 5. Medications: Combivir 300mg tab, bid, Benzapril 40mg daily, Amlodipine 10 mg tab daily. 6. Over the Counter Medication and Nutritional supplements: One a Day multi-vitamin. 7. Immunizations: Flu
Past Surgical History 1. Hospitalization: Yes, Dec 2012 for pneumonia. 2. Outpatient Care: HIV clinic, HTN follow-up. 3. Transfusions: none
Family History: 1. Immediate Family: 86 year mother with early stage of Alzheimer. 2. Extended Family: 3 cousins, no siblings
Psychosocial History: 1. Occupational History: Accountant 2. Education: Hunter College, master’s degree in accounting. 3. Children and ages: No children. 4. Exercise: Walking, YMCA two times per week. 5. Sexual History: Patient is sexually active
REVIEW OF SYSTEMS: 1. General – fatigue, recent weight loss, contributing factors (change in bowel pattern, insomnia, and altered appetite), night sweats, frequent infections, low energy. 2. Skin – Dry, flaky skin, pruritus, no lumps, no changes in skin texture, some hair loss, some grey hair noted. 3. HEENT – Head: Denies headaches, dizziness. Eyes: Denies blurred vision, wears glasses for reading; no discharge. Last eye exam was August 10, 2012. Ears: Denies hearing problem, no pain or discharge. Nose and sinuses: good sense of smell, no sinus problem. Throat/mouth: Denies hoarseness, change in voice, no oral lesions, bleeding gums/gum sensitivity, no difficulty chewing/ swallowing, last dental exam March, 2012 4. Neck & Lymphatic – Denies any stiffness/pain, no swelling noted. 5. Chest – Denies any changes in breast size, no lumps or discharge. 6. Respiratory – frequent colds (twice a year), sputum production, pneumonia (hospitalized in 2012), date of last chest x-ray examination 2012, date of last tuberculin test 2011 and result was negative. 7. Cardiovascular– Hypertension. Denies chest pain, heart murmurs. 8. Gastrointestinal – Report frequent loose BM, poor appetite, abdominal pain, increase flatulence. Last colonoscopy was done in 2011 9. Urinary – frequent urination, denies change in color, no suprapubic pain. 10. Male Reproductive- Denies any sexual dysfunction. Patient reports using condom with female partner. Denies testicular pain or discomfort, no abnormal discharge. 11. Musculoskeletal-Denies any bony deformities, swelling or weakness. Patient complained of stiffness in the both shoulders and right knee pain. Pain rated 4/10 13. Neurologic- Alert and orientated to person, time and place, no memory problems. Denies change in balance, loss of movement, change in sensory perception, change in speech, change in smell, and normal range temperature. 14. Hematologic- Denies easy bruising/bleeding, blood type B+. 15. Endocrine-Denies thyroid trouble, cold intolerance, changes in body hair distribution. 16. Psychiatric- Anxious about his mother’s Alzheimer and his recent hospitalization. Feels stresses and depressed, difficulty sleeping at nights.
PHYSICAL EXAMINATION: 1. General Survey- Patient general appearance is congruent with his stated age. He is alert and oriented x3. Normal posture, gait is steady, movements smooth and effortless. He is clean and appropriately dressed, hygiene is good. He complained of 3/10 pain in shoulders, height 5ft.3in. Weight 102 lbs. Speech is clear and coherent, normal pitch, rate, and volume. Facial expression is congruent to situation. 2. Vital Signs – B/P-138/90, P-89, R-18, O2sat- 99% on room air. 3. Skin-No lesions, cuts or bruises noted, skin is dry, nut remains intact. 4. HEENT- Head: fine and gray hair, some baldness noted to the top of the head. Eyes: vision 20/25, symmetrical eye movement, sclera white, no discharge, wears glasses for reading. Ears: no hearing loss, no complaint of pain or discomfort. Nose and sinuses: normal nasal speculum. Throat: dry lips, gums and oral mucosa slightly red. 5. Neck- Supple neck with no vein distended. 6. Anterior & Posterior Thorax and Lungs- Lungs are clear bilaterally with no crackles noted. Symmetrical chest expansion noted bilaterally. 7. Breasts –Equal bilaterally, no pain, swelling, or discharge. 8. Cardiovascular System- Pulse is 89 and EKG is normal. 9. Abdomen- Non-tender, non-distended, with hyperactive bowel sounds in all four quadrants. 10. Lower Extremities – No swelling or edema, pulse equal bilaterally. 11. Nervous System- Alert and oriented times 3 to person, place and time. No gross deficits noted. 12. STAGE OF DEVELOPMENT ACTUAL FINDINGS
Generativity vs Stagnation Patient is in the stage of Generativity. •Mr. Ruiz assists the members of his church with their taxes. •He volunteers to serve meals to the homeless. •Donate food and clothing to the homeless
Plan of care and referrals 1.Refer client to primary care provider and encouraged the need for follow-up care and to have labs done. Labs such as CBC, HIV viral load, urinalysis, liver function test. 2.Assess for suicidal and homicidal ideation and refer for counseling. Teach stress reduction exercises such as deep breathing exercise, music, and encouraged patient to walk a few blocks daily. 3.Refer Mr. Ruiz to an HIV knowledgeable dietician, monitor weight, encouraged him to eat small, frequent, high caloric meals daily. Teach the patient to prepare less spicy meals, encouraged him to eat less fried food. He could also include Ensure or Boost in his diet to make sure his nutritional needs are met. 4.To reduce infections we would encourage frequent hand washing, safe preparation of food, encouraged use of over the counter supplements such as Emergen-C to boost the immune system. 5.For sleep we would encouraged a warm cup of tea, pre-recorded relaxation CD to help patient with sleeping. If that doesn’t work we could ask MD to prescribed Ambien 5/10 mg at bedtime for sleep. 6.We would also encouraged patient to eat food such as rice, banana to make stool less soft. 7.Encouraged 2 L fluids. Monitor BP, encouraged low sodium foods. 8.Refer for dental check up, encouraged client to rinse with salt water daily, instead of using harsh mouth wash. 9.Refer the client to social services for available resources and to get assistance for his mother, such as homecare services. 10.Refer the patient to a HIV support group and also for drug assistance program to get help with his medication. 11.Client is also given written resources on hypertension and HIV and was assisted to get on the website The Body where he could additional information on HIV. Encourage visits every 3 months and weekly phone calls to ensure patient has been compliant with medications and that the issue of frequent urination, diarrhea and weight loss is resolved. 12.Teach the patient to take medications as ordered, advice him about possible side effects and their management. 13.Encouraged the client to wear condoms during sexual intercourse. Refrain from oral and anal sex.
Cultural Assessment Mr. Ruiz is a 42 year old Hispanic male, whose mother and father migrated from Puerto Rico to the United States when he was just 10 years old. He reported that he learned English while attending school, but his family communicated with him in Spanish, so he speaks fluent English and Spanish. According Transcultural nursing, Puerto Ricans are fond of celebrations, they like festival and family gatherings, so the community health nurse should be aware that family involvement is very important for Mr. Ruiz. She nurse should also be aware of her tone when communicating with Mr. Ruiz, as a high pitch tone and may appear as confrontational to the patient. Puerto Ricans are accustomed to shaking hands when greeting people. They might even avoid eye contact when communicating out of respect. The community health nurse should also be aware that family members generally prefer to provide support for individuals needing care in the home themselves and it might take awhile for Mr. Ruiz to agree to have home care for his elderly mother. Puerto Ricans are members of the Roman Catholic faith, they do believe that destiny, Deity or spiritual force control events that occur, such as illness/health and death. Illness maybe contributed to heredity, sin, an evil spirit, or a lack of disharmony of environmental forces within the individual. A disharmony of environmental forces can be treated with food, herbs, and medicines which will restore a positive internal harmony, so it’s important to assess for over the counter medications and any use of herbal supplements. Many Hispanics also believe in hot and cold disease. A treatment of a hot disease is with cool or cold remedy, while treatment of a cold disease is with a hot remedy. Example, Mr. Ruiz have diarrhea which is considered a hot illness, can be treated with cold treatment of bicarbonate of soda so the nurse needs to assess what treatment intervention he has attempted. HIV virus has affected one in every seven Hispanic Americans and one in every four African Americans, so we should educate Mr. Ruiz on reducing risky behaviors and encouraged the use of condom every time he has sex.
