NURS-6512N WEEK 2 DIVERSITY AND HEALTH ASSESSMENTS DISCUSSION

CASE STUDY 1

John Green, 33 year-old Caucasian male, presents to the office to establish as a new patient. John’s natal sex is female but he identifies as a male. He transitioned from female to male 2 years ago. He has made a full transition with family and socially last year. He just moved back home and is unemployed at this time. He has been obtaining testosterone from the internet to give to himself. He has not had any health care since he decided to change other than getting his suppression medications through Telehealth 3 months ago. His past medical history includes smoking 2 packages of cigarettes per day for the last 10 years, smokes 3-6 marijuana joints every weekend (has an active green card), and does suffer from depression episodes. He is HIV positive for the last 3 years but remains virally suppressed at his last blood draw 6 months ago. He has been feeling very weak over the last few weeks which prompted him to move back home with his parents. He takes Biktarvy once daily that comes in the mail for free, tolerates it well, and 100 mg Testosterone IM every 7 days. His PMH is non-contributory. No past medical history. He has never been married. No significant family history. He is worried since moving back home and unemployed he will be a burden on his family, and he thinks his health may be declining.

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CASE STUDY 2

Shawn Billings, a 28 year-old African American patient comes in to the clinic today. He has been deemed a “frequent flyer” by the staff at the clinic and was at the clinic last week and 4 days ago with a migraine, given a shot of Toradol and Ativan and sent home. He is here today again for an extreme headache. He is very agitated today. He is here with his father and worried that he will not get any medication.

NURS-6512N WEEK 2 DIVERSITY AND HEALTH ASSESSMENTS DISCUSSION POST

John, is a 33-year-old caucasian male, non-married, transgender patient who presents with complaints of depression, and declining health concerns. John prefers the pronouns he/him/his.

Socioeconomic Status

John is currently unemployed and does not provide further information on this status change. Currently living with, and dependent on his parents for support currently. Due to the circumstances, John should receive a mental health screening. The patient admits to feeling like a burden and unhappy about his current life status at the moment. A depression screening, or PHQ-9 screening, can assign a numerical value to the patient’s thoughts and feelings, allowing the provider to have a better understanding of the patient’s cognitive state.

Also, Studies show that the prevalence of suicidal thoughts and attempts among transgender adults is significantly higher than that of the U.S. general population; 51% of transgender patients have attempted suicide in 2015, and statistically, this number is most likely higher today (Suicide thoughts and attempts among transgender adults 2020). A suicide screening is essential with transgender patients at every visit. This patient would benefit from a counselor or mental health professional, trained in LGBTQ patients, to talk to on a regular basis.

Medical History

John is HIV Positive, sexually active, and currently transitioning from male to female, no reassignment surgery was noted. The patient is currently transitioning from female to male. Otherwise, medical history is non-contributory. John gets routine treatment and management from a physician for his HIV medications and care.  Since John admits to getting testosterone from an online website, it is important to explore this medication more. I would want to know if John is taking an appropriate dose. Is this medication safe, since possibly bought outside of FDA regulations? Lastly, does this medication interact with his prescription of Biktarvy that the takes for HIV? It would be important to review his HIV status. He has had labs and saw a provider about 6 months ago. But as a provider, it will be important to gather a good health history for this patient.

Social History

It is important for a provider to have a clear understanding of the patient’s social history. John is a smoker, 2 pack/day for 10 years. Recreational Illicit drug use on weekends, Lives with parents. Recently “came out” to his parents and publicly. As a provider, I would need to dig deeper into each of these subjects. What are Johns’ thoughts about smoking, would be interested in quitting smoking? The patient’s use of marijuana would need to be explored. How much and how often does John smoke? Does he do any other illicit drugs? And, lastly, why does he choose to participate in these illicit drugs?

Transgender people are more likely to be sexually abused, become sex workers, and experience intimate partner violence. Surveys conducted with the transgender population reveal that 50% of the transgender population have been hit by a partner after coming out as transgender (Office for Victims of Crime, 2014). As a provider you will need your patients to have great trust, rapport and feel safe in order to explore topics like this. There are trainings that providers can take to help them become more culturally aware, informed and understanding of the LGBQT community. One of these programs is called Safe-Zone Training (The Safe Zone Project n.d). Questions a provider should ask are, What type of sexual activity are they having? What sex are these partners? Use of protection while sexually active? And, while biologically this patient is assigned a female gender, is there any chance of pregnancy? Do you inform your sexual partners about your HIV status?

Cultural/Lifestyle Sensitivity

A practicing provider today needs to practice gender-affirming care. Gender-affirming care is designed to support and affirm one’s gender identity while proving medical care, building rapport, trust, and security that one will not be judged or criticized for their gender identity. Many patients of the LGBTQ community, due to discrimination and shaming are experiencing high levels of gender dysphoria. This is a state of psychological distress that comes from the disconnection between gender assignment and the identity they are experiencing (Boyle & Writer, 2022).

Spiritual-Religion/Cultural Factors

John does not disclose his religion or spiritual beliefs. It is likely that John does not have a close affiliation to a religion, as he does not report any supportive sources. Even with the level of awareness and forth-coming about one’s sexuality/sex in today’s communities, 53% of religiously unaffiliated Americans believe that society has not gone far enough in accepting the transgender population (Lipka & Tevington, 2022). This further supports why providers even need to be more supportive when caring for a transgender/LGBTQ patient.

Barriers to Health Care

Transgender adults face barriers to health care that may be due to a variety of reasons, including discrimination in health care, health insurance policies, employment, financial, and public policy, or lack of awareness among healthcare providers on transgender-related health issues. Barriers to healthcare exist for all patients. Some barriers for healthcare are insufficient insurance coverage, healthcare staffing shortages, language barriers. John may be in need for assistance paying for his medications and other healthcare needs since he is currently unemployed. John also may be hesitant to seek care due to bias or judgmental of his life choices.

5 Targeted Questions for John

Evaluating the patients mental health is key. The following are a few questions to determine his suicide risk,.

• Have you wished you were dead or wished you could go to sleep and never wake up?
• Have you had thoughts of harming yourself?
• Have you ever attempted to harm yourself in the past, with the intent to end your life?

Other questions I would ask the patient may revolve around his sexual activity and history.

• Do you have sex with men, women, or both?
• Do you use condoms with both vaginal and/or anal sex?
• How many sexual partners have you had in the past year?

 

References

Boyle, P., & Writer, S. S. (2022, April 12). What is gender-affirming care? your questions answered. AAMC. Retrieved March 8, 2023, from https://www.aamc.org/news-insights/what-gender-affirming-care-your-questions-answered

Gerritse, K., Hartman, L., Antonides, M. F., Wensing-Kruger, A., de Vries, A. L. C., & Molewijk, B. C. (2018, November). Moral challenges in transgender care: A thematic analysis based on a focused ethnography. Archives of sexual behavior. Retrieved March 8, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6245036/#:~:text=Six%20main%20themes%20of%20moral,6)%20decision%2Dmaking%20process.

Lipka, M., & Tevington, P. (2022, July 7). Attitudes about transgender issues vary widely among Christians, religious ‘nones’ in U.S. Pew Research Center. Retrieved March 8, 2023, from https://www.pewresearch.org/fact-tank/2022/07/07/attitudes-about-transgender-issues-vary-widely-among-christians-religious-nones-in-u-s/

Loyal |. (2020, April 9). Suicide thoughts and attempts among transgender adults. Williams Institute. Retrieved March 8, 2023, from https://williamsinstitute.law.ucla.edu/publications/suicidality-transgender-adults/

Office for Victims of Crime (OVC). (2014, June). The numbers. Sexual Assault: The Numbers | Responding to Transgender Victims of Sexual Assault. Retrieved March 8, 2023, from https://ovc.ojp.gov/sites/g/files/xyckuh226/files/pubs/forge/sexual_numbers.html

What is safe zone? ” The Safe Zone Project. The Safe Zone Project. (n.d.). Retrieved March 8, 2023, from https://thesafezoneproject.com/about/what-is-safe-zone/

 

 

response

This is an informative post, I really enjoyed it. To add on your post, I will analyze the targeted questions that you plan to ask your patients. First and foremost, mental assessment on the patient as a nurse helps in giving a clear picture on how the nurse will reason or think out the patient problem (Välimäki et al., 2022). Your question on suicidal risk are meant to check if the patient is capable of harming himself. Some of the other areas that you could have based as a nurse are questions on personal history such as work history, marital status, current social situation, issues with alcohol or drugs among others. The question on suicidal thoughts would also be applicable to the patient I interviewed because one of the symptoms that I noticed was depression, this would be beneficial in preventing the patient from causing harm to himself. The importance of the assessment questions helps in decision making and diagnosis. As per Aboraya et al., (2016),  health providers use patients; responses to observe their behavior and make final rating of signs and symptoms.

References

Aboraya, A., Nasrallah, H., Muvvala, S., El-Missiry, A., Mansour, H., Hill, C., … & Price, E. C. (2016). The Standard for Clinicians’ Interview in Psychiatry (SCIP): A Clinician-administered Tool with Categorical, Dimensional, and Numeric Output—Conceptual Development, Design, and Description of the SCIP. Innovations in clinical neuroscience, 13(5-6), 31.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5077257/

Välimäki, M., Lantta, T., Lam, Y. T. J., Cheung, T., Cheng, P. Y. I., Ng, T., & Bressington, D. (2022). Perceptions of patient aggression in psychiatric hospitals: a qualitative study using focus groups with nurses, patients, and informal caregivers. BMC psychiatry, 22(1), 344.https://link.springer.com/article/10.1186/s12888-022-03974-4Links to an external site.

 

NURS-6512N WEEK 2 DIVERSITY AND HEALTH ASSESSMENTS DISCUSSION Case Study

Patient History

John Green, 33 year-old Caucasian male, presents to the office to establish as a new patient. John’s natal sex is female but he identifies as a male. He transitioned from female to male 2 years ago. He has made a full transition with family and socially last year. He just moved back home and is unemployed at this time. He has been obtaining testosterone from the internet to give to himself. He has not had any health care since he decided to change other than getting his suppression medications through Telehealth 3 months ago. His past medical history includes smoking 2 packages of cigarettes per day for the last 10 years, smokes 3-6 marijuana joints every weekend (has an active green card), and does suffer from depression episodes. He is HIV positive for the last 3 years but remains virally suppressed at his last blood draw 6 months ago. He has been feeling very weak over the last few weeks which prompted him to move back home with his parents. He takes Biktarvy once daily that comes in the mail for free, tolerates it well, and 100 mg Testosterone IM every 7 days. His PMH is non-contributory. No past medical history. He has never been married. No significant family history. He is worried since moving back home and unemployed he will be a burden on his family, and he thinks his health may be declining.

Patient Risk Factors and Health Assessment

There are numerous socioeconomic, spiritual, lifestyle, and cultural factors that have influence and continue to influence John Green’s health. Considering that he is a transgender individual, it is likely that he faces discrimination and social stigma (Hines, Laury and Habermann, 2019). In addition, being unemployed and dependent on his family for support are also likely to affect his mental and emotional well-being. There is also the issue of smoking, marijuana use, and identified incidences of depression are other reasons impacting his health. It is also worth noting that the fact that he is HIV positive compounded by a general lack of regular healthcare have significant implications for his physical health.

It is a key requirement for clinical practitioners to build health history for patients especially those that present for the first time (Truong, Paradies and Priest, 2018). To build John’s health history, I would frame my questions in a way that is sensitive to his background, lifestyle, and culture. For instance, I would start by asking about his gender identity and how it has impacted his healthcare experiences. After this, I would then ask about his smoking and marijuana use, his depression episodes, and his HIV status and management. There are five targeted questions that would aid me on this and these are;

1. Tell me about your gender identity and how it has affected your healthcare experiences?
2. How long have you been smoking cigarettes, and how many do you smoke per day?
3. Describe your marijuana use, including how often you use it and how it affects you?
4. How do you manage your depression episodes, and have you sought any treatment?
5. How have you been managing your HIV status, and have you had any recent blood draws to check your viral load?

Communicating with patients from diverse cultural backgrounds often present challenges for nurses and a key strategy is to approach patients with an open mind and a willingness to learn about their culture and beliefs (Seelman et al., 2017). When need be, nurses can use the services of and to promote effective communication. Importantly, it is essential to avoid making assumptions and to ask open-ended questions that allow patients to share their experiences and concerns.

  

References

Hines, D. D., Laury, E. R., & Habermann, B. (2019). They just don’t get me: A qualitative analysis of transgender women’s health care experiences and clinician interactions. The Journal of the Association of Nurses in AIDS Care, 30(5), e82. https://doi.org/10.1097/JNC.0000000000000023Links to an external site.

Seelman, K. L., Colón-Diaz, M. J., LeCroix, R. H., Xavier-Brier, M., & Kattari, L. (2017). Transgender noninclusive healthcare and delaying care because of fear: connections to general health and mental health among transgender adults. Transgender health, 2(1), 17-28. https://doi.org/10.1089/trgh.2016.0024Links to an external site.

Truong, M., Paradies, Y., & Priest, N. (2018). Interventions to improve cultural competency in healthcare: a systematic review of reviews. BMC health services research, 14(1), 1-17. https://doi.org/10.1186/1472-6963-14-99Links to an external site.

 

NURS-6512N WEEK 2 DIVERSITY AND HEALTH ASSESSMENTS DISCUSSION  CASE STUDY 2

Initial Post:

Specific Socioeconomic, Spiritual, Lifestyle, and Other Cultural Factors Associated With the Patient

My patient is a 28-year-old African American who presents to the clinic with an extreme headache and agitation. He was at the clinic last week and four days ago with a migraine. He was treated with Toradol and Ativan prior to discharge. Today, he came with his father and is worried he will not get any medication. This patient may have the assumption based on his frequency of visits, ability to pay for care, or a previous experience with healthcare staff. My job today is to listen, understand, and provide quality care to the best of my ability.

Research has shown minority groups experience greater health disparities. According to the Centers for Disease Control and Prevention (2017), African Americans experience more economic or social differences that can influence their health than whites. Specifically, they report a higher number of African Americans face unemployment, poverty, and obesity which have direct correlations to health. During today’s visit, I will attempt to collect as much information as I can and collaborate on a treatment plan that reflects his values and goals.

How To Build a Health History For the Patient

To build a health history for my patient, I will present with a calm and professional demeanor, engaging in eye contact and active listening to promote a non-judgmental and safe environment for him to share information. I will demonstrate curiosity and ask for clarification if he references something I am not familiar with, such as a particular homeopathic treatment that may be common in his culture. Also, as his father accompanied him to this visit, I will ask the patient if he wishes for his father to stay in the room or step out while we talk and perform an examination. These strategies will assist in cultivating a positive patient-provider interaction.

Targeted Questions to Ask to Build His Health History and Assess His Health Risks

• What are your goals for this visit? (e.g., pain relief, discovering the cause of the headaches, or finding ways to prevent headaches)
• Have you had any recent major life changes? (e.g., loss of employment, income, housing, relationship status change, or serious illness or loss of a close relative or friend)
• What are your usual diet and sleep patterns?
• I know your father is with you, what other sources of support do you have?
• Do you have any specific values or beliefs related to your health such as traditional vs. modern medicine?

Strategies to Employ to be Sensitive to Different Cultural Factors 

According to Young and Guo (2020), cultural diversity variables can increase the opportunity for miscommunication with our patients. Providers need to be culturally competent, adaptable, and genuinely curious about their patient’s culture, beliefs, and values to foster a trusting relationship (Ball et al., 2019, p. 22). As practitioners, we need to approach each person as an individual. One model we can utilize in our interactions with patients is the RESPECT Model which is patient-centered and includes rapport, empathy, support, partnership, explanations, cultural competence, and trust (Ball et al., 2019, p. 31). This model can assist us with better understanding patients from different cultures and treating them as individuals.

 

 

References:

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (Eds.). (2019). Cultural competency. Seidel’s guide to physical examination: An interprofessional approach (9th ed., pp.22-31). St. Louis, MO: Elsevier Mosby.

Centers for Disease Control and Prevention. (2017, July 3). African American Health. Centers for Disease Control and Prevention. https://www.cdc.gov/vitalsigns/aahealth/index.htmlLinks to an external site.

Young, S., & Guo, K. L. (2016). Cultural diversity trainingLinks to an external site.. The Health Care Manager, 35(2), 94–102. https://doi.org/10.1097/hcm.0000000000000100Links to an external site.

NURS-6512N WEEK 2 DIVERSITY AND HEALTH ASSESSMENTS DISCUSSION SAMPLE POST 2

Cultural Competence

Cultural competence starts with considering and improving cross-cultural communication as a healthcare provider (Ball et al., 2019). The RESPECT model can be used as a tool for healthcare providers to assure that the patient is receiving patient-centered care (Ball et al., 2019). Rapport, empathy, support, partnership, explanations, cultural competence, and trust are the steps of using RESPECT (Ball et al., 2019). For the cultural competence piece, it is imperative that the healthcare provider understand their own preconceptions and cultural biases that they hold (Ball et al., 2019). This paper will use the RESPECT model in a case study of a 28-year-old African American male patient with migraines that has been labeled a “frequent flyer”.

Rapport should be used with this patient as he has been seen several times prior without having symptoms resolved. Rapport should include not making assumptions, so even though the patient is known as a frequent flyer he should be treated with respect and lack of judgement (Ball et al., 2019). Gathering information such as “when did the symptoms start” and “how long have they been going on” can be used as well as “tell me the story of your migraines and treatment so far” (Ball et al., 2019).

Empathy should be used as this patient is in pain and is seeking treatment due to it, and in so asking for help (Ball et al., 2019). Simply acknowledging that the patient has been experiencing a major health stressor can show empathy for the patient and his agitation may diminish if he feels he is being believed (Ball et al., 2019). The patient’s agitation maybe due to not being taken seriously in the past. Befus et al. (2018) highlighted that African American patients were less likely to receive a diagnosis of migraine and the subsequent migraine treatments. The patient has received abortive medications in the past (Toradol and Ativan) but not medications used for prophylaxis of migraines such as CGRP receptor antagonists or tricyclic antidepressants (Rosenthal & Burchum, 2021).

Support is the third step and an important one for the patient (Ball et al., 2019). The patient is agitated and worried he will not receive medications. The patient is showing his underlying fear, that the headache will not go away and that this trip to see a healthcare provider was a waste. Understanding what the patient believes to be his barriers to care will help in understanding how to approach the problem (Ball et al., 2019). Asking the targeted question “what do you feel has been a barrier to your treatment of the migraines in the past” can help guide today’s treatment (Ball et al., 2019). This leads to the forth element of RESPECT, which is partnership (Ball et al., 2019). Showing the patient that he is working with the healthcare provider, and the dad if wanted, as a team to approach a solution (Ball et al., 2019). Asking the patient “what do you think will help the migraine” or “what has worked in the past for your migraines” can bring forth the expectations of the patient for this visit. To work in partnership, all parties need to understand the expectations of care (Ball et al., 2019). With having the father present, a question should be posed of the family history of migraines. Migraines can have a familial trend (McCance & Huether, 2019). The patient may not know some of the family history and the father could add in information.

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            Explanations is the next step in the process in which the healthcare provider needs to frequently check in and make sure that there is clear understanding of the problem (Ball et al., 2019). Using a statement such as “to make sure I am understanding correctly, you stated” with a repeat back of what the patient stated (Ball et al., 2019). Using the patient’s own words and clarifying areas that were murky can assist in making the patient feel heard (Ball et al., 2019). Also, making sure the patient is understanding the conversation as it moves through the visit (Ball et al., 2019) NURS-6512N WEEK 2 DIVERSITY AND HEALTH ASSESSMENTS DISCUSSION .

Cultural competence is a piece of the RESPECT model that may make healthcare providers nervous to approach as they can be sensitive topics (Ball et al., 2019). Healthcare providers ask many personal questions that most people would not tell a stranger. Some cultures are more open with topics than others (Ball et al., 2019). Using an approach that is respectful to the culture of the person is of the utmost importance (Ball et al., 2019). For example, some cultures do not find it appropriate to look someone in the eyes while speaking, so these factors should be taken into consideration especially while asking sensitive questions (Ball et al., 2019). Questions should be geared at finding any cultural, lifestyle, spiritual/religious, or socioeconomic factors that may affect the care of the patient, or have in the past (Ball et al., 2019). They should be asked in a respectful manner while placing any biases that the healthcare provider hold aside (Ball et al., 2019).

High amounts of stress, lack of sleep, and certain types of foods can trigger migraines (McCance & Huether, 2019). Cultural practices can dictate what people eat, their work ethic, and even sleep patterns, among other factors (Ball et al., 2019). Asking questions such as “what foods have you been eating on a regular basis over the last several months” can help give a clearer picture on possible migraine triggers (McCance & Huether, 2019). Another question that should be asked is “have you tried anything else for the migraine” which can assist in ascertaining the use of complementary/alternative or herbal therapies (Ball et al., 2019). Asking sensitive questions such as “what was your gender at birth” can add in pieces of the puzzle. Migraines have higher rates in women, especially around menstrual cycles (McCance & Huether, 2019). If the patient was born female or is taking hormones to transition to female, the estrogen levels could be triggering migraines (McCance & Huether, 2019). Pace et al. (2021) found that the increased stress of being transgender increased migraine rates in the transgender population. Psychiatric comorbidities, such as anxiety and depression, often seen in sexual minority groups, could add valuable information to migraine studies, yet there are no migraine studies in this population (Pace et al., 2021). Asking “how do you identify” or “do you have any worries associated with your sexual identity” could help to uncover a possible migraine trigger.

Trust is last but not least of the RESPECT steps (Ball et al., 2019). If a patient trusts a healthcare provider they may divulge information that they wouldn’t previously have (Ball et al., 2019). This all has to do with trust. If a patient does not feel they can trust you as a healthcare provider, it may be time to admit the partnership is not working and have another healthcare provider take over their care (Ball et al., 2019).

Cultural competence is a fluid concept in which the healthcare provider should be constantly learning and adjusting practices (Ball et al., 2019). One of the most important ways of doing this is to learn from our patients (Ball et al., 2019). Gathering feedback on patient’s perceptions of the visit can assist the healthcare provider to grow their cultural competency and humility (Bell et al., 2019).

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional

           approach, (9th ed.). Elsevier.

Befus, D. R., Irby, M. B., Coeytaux, R. R., & Penzien, D. B. (2018). A Critical Exploration of Migraine as a Health Disparity: the Imperative

of an Equity-Oriented, Intersectional Approach. Current Pain and Headache Reports, 22(12), 79. https://doi.org/10.1007/s11916-

018-0731-3

McCance, K.L. & Huether, S.E. (2019). Pathophysiology: The biologic basis for disease in adults and children, (8^th ed.). Elsevier.

Pace, A., Barber, M., Ziplow, J., Hranilovich, J. A., & Kaiser, E. A. (2021). Gender Minority Stress, Psychiatric Comorbidities, and the

Experience of Migraine in Transgender and Gender-Diverse Individuals: a Narrative Review. Current Pain & Headache

           Reports, 25(12), 1–9. https://doi.org/10.1007/s11916-021-00996-7

Rosenthal, L.D. & Burchum, J.R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants, (2^nd ed.) NURS-6512N WEEK 2 DIVERSITY AND HEALTH ASSESSMENTS DISCUSSION .