(NUR MISC Misc) Day 1 Healthcare Disparities STUDENT HANDOUT GUIDE.

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(NUR MISC Misc) Day 1 Healthcare Disparities STUDENT HANDOUT GUIDE. Detail Clinical Significance/Impact History of present illness: Mr. Reyes is a 62-year- old Hispanic male. He arrives to the All Ac... cess Health Clinic with a complaint of left eye pain with “yellow” drainage that started yesterday. He has been seen here before. The patient was seen once already and is back to the clinic again. Patient c/o left eye pain with yellow drainage. Social History: Mr. Reyes moved to the United State 10 years go from Mexico with his adult son and daughter. Spanish is his primary language. He can speak some English but not fluently. He is accompanied by his daughter, daughter-in-law and four grandchildren. The exam room is crowded and chaotic with the family present. His oldest granddaughter, Eleiyah, is translating for him today. She is 12 years old. Mr. Reyes is self- employed and owns his own bricklaying company. He works full-time and is often out on job sites working during the day. The patient's family orientation can interfere with his plan of care. The language barrier is also important because they have a 12 year old as the translator which can also interfere with the care plan. The patients current work condition can have an impact on his care plan. Medical History: Mr. Reyes has a history of chronic hypertension and a lower back pain from a fall he experienced ten years ago. According to his medical record, he prescribed Lisinopril 10 mg daily. He also takes ibuprofen occasionally for back pain and is on a Dash diet. Patient had chronic hypertension and a lower back pain from a fall. It is important to understand the patient has hypertension to create a care plan that is compliant with that. Subjective History (from granddaughter): The nurse relies on Mr. Reyes’s granddaughter to translate for him. Eleiyah reports her mom is worried about Mr. Reyes. She had to “beg” him to come to the doctor about his eye. She states he works very hard in the heat. Lately he always seems tired and thirsty and his clothes “don’t fit right, they look too big.” The subjective history that was given to the nurse by the 12 year old granddaughter would have been more reliable if it was gained from a professional translator. It would have better for the patients overall care if the nurse were to have the patient talk to a translator so that there is a more reliable subjective history. Nursing Assessment: It was a busy clinic day. The nurse was frustrated by the language barrier and the chaos in the exam room. She felt she did not have time to contact a translator and did not ask Mr. Reyes further about his fatigue or potential weight change. She also did not review his medication list nor the management of high blood pressure. Patient did not understand the his diet and he didn’t understand how to take his eye drops. He was experiencing new symptoms had experienced significant weight loss. Nurse did not offer a translator and did not provide the proper care for him. Objective Data General Appearance: Resting in chair, talking to family, no acute distress noted. RESP: Not Assessed. CARDIAC: Skin pink, warm and dry to touch. NEURO: Alert & oriented to. person/place/time/situation. GI: Not Assessed. The nurse should do head to toe assessment, address his pain, any allergies. Respiratory rate should have been assessed because it was slightly elevated. The patients pain level was not assessed either which would have been important. Liquid input and output should have also been assessed. GU: Not Assessed. SKIN: Left eye is red with purulent drainage. No discharge noted to right eye. No other lesions noted. Lips moist. Vital Signs Clinical Significance/Impact P 76 Nurse should address pain and ask if patient was properly taking his BP medication. T 37.0 (98.6 F) R 20 BP 146/96 Weight 180.5 lbs. Height 5’7” (81.9 kg) Pain 5/10 Mr. Reyes is examined by the physician. He is prescribed Gentamicin sulfate antibiotic eye drops. Two drops to the left eye twice daily for ten days. The nurse speaks to Eleiyah directly and reads the prescription for Mr. Reyes’ to his granddaughter. The nurse asks her if she understands. Mr. Reyes’ granddaughter nods her head. Patient education for infection control using proper hand washing. Before the patient is discharged the patient should be properly educated on medication and caring for his eye. Explaining all this to the granddaughter is not helpful because she may not be able to fully understand everything the nurse is talking about. Test your knowledge! 1. What type of health disparity has Mr. Reyes experienced? 2. What factors contributed to Mr. Reyes not receiving the standard of care? 3. What additional assessments should have been completed at this time? Ethnicity Language barrier. Patient speak the language but not speak fluently Attitude of the nurse. Nurse did not get proper translator and address directly to the patient while explain the medication how to use. Age of the translator. His granddaughter my not understand what the nurse said. Nurse should completed patient health history. 4. What additional education could have been completed at this time? Asking patient about complaints of fatigue. Asking the patient the most accurate list possible of all medications patient is taking Asking last 24 Hour food that he ate. Education how to proper administration of eye drops. Follow up appointment. Case Study-Continued-Assessment Clinical Significance/Impact History of present illness: Mr. Reyes returns to the All Access Health Clinic one week later. You are the nurse this weekend. He is accompanied by his daughter and four grandchildren, including his 12-year-old granddaughter, Eleiyah. Eleiyah is fluent in English. Mr. Reyes’ left eye is red with yellow drainage. You recognize the adult members of the family do not speak English. The All Access Health Clinic contracts with a translation services due to the high volume of non-English speaking patients they provide services for. The patient has returned with the same conditions and the patient has stopped taking the medication. This is because the patient was not properly educated. Subjective Data (from Mr. Reyes and Family): You complete your history of Mr. Reyes using the translation services. Mr. Reyes complains that his eye is not better. He wasn’t sure how to take the eye drops. He was putting two drops in both eyes twice daily. He quit using the eye drop three days ago because his eye wasn’t red anymore. The subjective data is more reliable this time around because there is now a translator. The patient is still having weight loss, the antibiotic was not completed, and the patient is still not compliant with blood pressure medication. This is all because the patient's granddaughter did not fully understand the patient education. Mr. Reyes’s daughter tells you (through the translator) she is also concerned because her father is always thirsty and tired, and his clothes are getting too big for him, even though he eats “all the time.” States they did not tell the doctor these concerns last week, because they told the nurse. You also learn Mr. Reyes did not understand his medication instructions. In addition to completing the course of eye drops, he was not taking his Lisinopril daily. He tells you that he only takes it if he “feels” like his blood pressure is high. While conducting your assessment you discover a translator was not used during the previous visit. You also realize Mr. Reyes was hypertensive last week and that he has lost 20 pounds over the past 6 months. Assessment Clinical Significance/Impact P 68 Education diet patient overweight. The patient is still overweight, but their respiration and heart rate have gone down. T 37.0 (98.6 F) R 19 BP 130/90 Weight 180 lbs. (81.6 kg) Height 5’7” Objective Data General Appearance: Resting in chair, talking to family, no acute distress noted. RESP: Not Assessed CARDIAC: Skin pink, warm and dry to touch. Capillary refill <3seconds. NEURO: Alert & oriented to person/place/time/situation. GI: Not Assessed GU: Not Assessed SKIN: Left eye is red with purulent drainage. No discharge noted to right eye. No other lesions noted. Lips moist. The patients is still overweight so the patient's blood sugar should have been assessed because they are at risk for diabetes. The patients GI should have also been assessed because they are still experiencing some abnormal weight loss. Heart rate and respiratory should have been assessed. You prepare to brief Dr. Smith to see Mr. Reyes. What information is important to share? Practice SBAR: S: This is student nurse F.Osman calling regarding Mr. Reyes a 62-year-old Hispanic male. He is being seen today c/o his left eye. He is accompanied by his daughter daughter-in-law and four grandchildren His primary language is Spanish and his 12 year-old granddaughter translates whenever he doesn't understand the nurse. B: Mr. Reyes was seen in the clinic on one week ago and received treatment for an infection of his left eye. He was given a prescription for gentamycin drops. He is not compliant with the medication as prescribed. He takes Lisinopril, but only takes when he thinks his blood pressure is elevated. A: His left eye is red with purulent drainage. Over the past six months he lost 20 pounds. His daughter stated that his clothes are too big, he is always thirsty and more fatigue than usual. R: A translator is called and on the phone line. I will review the patient medication instructions with him. Do you want me to check his FSBS, and lab work for HbgA1C? any medication order? Case Study Continued Clinical Significance/Impact Dr. Smith is concerned Mr. Reyes may have Type 2 Diabetes Mellitus. You take his FSBS. It is 290 mg/dL. You have collected appropriate lab to confirm the possible diagnosis of Type II Diabetes. The physician has prescribed Glyburide. You explain how to use the medication. Utilizing the translator, you allow Mr. Reyes to repeat the instructions back to you. You have assisted in scheduling an appointment for Mr. Reyes to meet with an endocrinologist to confirm the diagnosis. You have also ensured he has an appointment with a diabetic educator and a dietician the following week. Mr. Reyes scheduled to come Patient self-employed may not have medical insurance. The patient may not have adequate transpiration to get to his follow up appointment . The language barrier may also have an impact on the follow up because he may not understand that he has to follow up. back next week. What factors could impact Mr. Reyes’ ability to follow-up appropriately? Communication-Understandable Explanations How would you explain Finger Stick Blood Sugar to Mr. Reyes? After washing your hands, insert a test strip into your meter. Use your lancing device on the side of your fingertip to get a drop of blood. Touch and hold the edge of the test strip to the drop of blood and wait for the result. Your blood glucose level will appear on the meter's display. Communication-Using a Translator Clinical Significance/Impact What are best practices regarding choosing a translator? The best practice is to use an facility interpreter if possible who is trained medical interpreter. It is important for healthcare professionals to be able to communicate effectively and efficiently with their patients no matter what language they speak. What are the disadvantages of using a family member? Family may not understand medical terms. Patient may not be comfortable sharing information in front of his family .Family interpreters may not be aware of health care procedures or medical ethics. Family members may become emotionally distressed at receiving upsetting medical news and may incorrectly interpret information or become unable to continue interpreting. A qualified medical interpreter can more impartially relate sensitive information, often with better judgment and bedside manner. What strategies can you use to work with interpreter? The best strategies to use interpreter is to speak slowly, maintain eye contact with the patient. Always talk to the patient not the interpreter , use only a simple language, with a few medical terminology as possible. Avoid raising your voice during the interaction and have more time. And ask for feedback from the patient to verify the patient understands . Don’t forget to document that was used interpreter for the patient medical record. Communication-CUS 1. As a nurse you are concerned about the safety and quality of the care Mr. Reyes received at the ALL ACCESS HEALTH Clinic. 2. Who will you follow up with and why? 3. What will you say to the previous RN who cared for Mr. Reyes? 4. Practice communicating with the first nurse who cared for Mr. Reyes. Use the CUS method. Did not communicated with other team and did not use Cultural Competence. I will follow with charge nurse, supervisor or manager. For improving healthcare professionals their practice. Mr. Reyes didn't understand the his diet and he didn’t understand how to take his eye drops. Also he was experiencing new symptoms had experienced significant weight loss since last visit. The nurse did not offer a translator and she did not provide the proper care for him. C-I am concerned for the patient care. U-I am uncomfortable with the nurse practice. S-This is a safety issue for the patient . Resources https://www.ahrq.gov/professionals/quality-patient-safety/hais/tools/ambulatory- surgery/sections/implementation/training-tools/cus-tool.html References  Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Camera, I. M. (2011). Medical-surgical nursing: Assessment and management of clinical problems (8th ed.). St. Louis, MO: Elsevier.  LeMone, P., Burke, K. M., Bauldoff, G., & Gubrud-Howe, P. M. (2015). Medical-surgical nursing: clinical reasoning in patient care. Sixth edition. Boston: Pearson. [Show More]

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