AG is a 54-year-old Caucasian male who was referred to your clinic to establish care after a recent hospitalization after having a seizure related to alcohol withdrawal. He has hypertension and a history of alcohol and cocaine abuse. He is homeless and is currently living at a local homeless shelter. He reports that he is out of his amlodipine 10 mg which he takes for hypertension. He reports he is abstaining from alcohol and cocaine but needs to smoke cigarettes to calm down since he is not drinking anymore.

Respond on or before Day 6 on 2 different days to at least two of your colleagues who were assigned a different patient than you. Critique your colleague’s targeted questions, and explain how the patient might interpret these questions. Explain whether any of the questions would apply to your patient, and why.

S. C

COLLAPSE

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According to Young and Guo (2020), culture is described as an individual’s or a population’s values, beliefs, practices, traditions, thinking processes, and conventions. One’s thinking, decision-making, and life views are all shaped by our cultural ideas. Even though ethnic cultures are diverse, each ethnic group has its cultural standards. Within a single ethnic community, not everyone shares the same customs or religious beliefs (Young & Guo, 2020). Therefore, when using a holistic approach to patient care, it is important to understand the patient’s cultural values, beliefs, and practices.

The assigned patient is a 54-year-old Caucasian man who suffers from hypertension and has a cocaine and alcohol abuse history. The patient was hospitalized recently after an alcohol withdrawal seizure. He is presently homeless and residing at a nearby homeless shelter. The patient reports he is out of Amlodipine 10 mg for his hypertension. He states he is free of alcohol and cocaine but still has to smoke cigarettes to relax because he is no longer drinking.

Socio-Economic, Spiritual, Lifestyle and Cultural Factors

A practitioner cannot assume spiritual practices or religious affiliations with any patient. People can convert to new religions at any time during their life. Therefore, it is essential to ask about religious preferences with all patients. The case scenario does not provide information on the patient’s nationality. However, if the patient is American per Ball et al. (2019), the patient may be direct in his conversations and come to the point quickly and prefer others to do so.

Being homeless causes a complete breakdown of ties with individuals the homeless use to live and socialize with. Mabhala et al. (2017) state that common maladaptive behaviors that cause the breakdown of social relationships are substance abuse, alcoholism, self-harm, and disruptive conduct.

Housing is a social determinant of health. According to Simms et al. (2020), homeless adults had sixty to seventy percent greater incidence of cardiovascular events than the general population. The need for overnight shelter, food, and clothes are all competing stresses. Barriers to regular care, such as a lack of insurance and the inability to get and store prescriptions, may be particularly widespread among the homeless (Simms et al., 2020). Housing insecurity was linked to putting off medical treatment and drugs, going to the emergency room more frequently, and having a higher likelihood of hospitalizations (Simms et al., 2020).

For disenfranchised communities, there are several hurdles to care. These include concerns about how the healthcare system serves the homeless, drug users, and individuals living in poverty. For homeless persons, patient issues like distrust of services and feeling undesired have been documented by O’Donnell et al. (2016). According to Basso da Silva et al. (2020), homeless individuals have their own social structure that aids them in overcoming the challenges of social acceptance as well as the insufficiency of the social assistance available to them. Drugs are a part of this culture as a way of life, and health professionals must understand and engage with them in a conscientious and open manner.

Sensitive Issues

           Sensitive issues like substance abuse can be challenging for some clinicians to talk about, but these issues must be discussed for the patient’s well-being. When the issue of drugs and alcohol was brought up, Moriarty et al. (2012) discovered that patients downplayed, reasoned, or offered defensive or socially acceptable replies. In addition, they were hesitant to discuss unlawful activities or socially undesirable conduct with providers. However, the authors discovered that using open-ended questions to start a discussion about alcohol and drug usage was particularly effective (Moriarty et al., 2012). Since the patient has said that he has given up drugs and alcohol, a referral to specialty treatment for a full assessment should be discussed with the patient.         

Targeted Questions

           Assessments should start with the patient’s allergies and sensitivities, family history of diseases, and a general review of systems. Since the patient came in for hypertension, questions surrounding his identified health need should be addressed first. Among the questions that would be asked include, are you on any other medications besides Amlodipine? When were you first diagnosed with hypertension? Have you ever taken other medications for your high blood pressure? If so, why was it discontinued?

           Moving on to substance abuse questions, how many standard alcohol drinks do you have on a typical day? What is the length of time that you have been drinking that amount? How often do you have 6 or more drinks on one occasion? How old were you when you started drinking alcohol? When was the last time you had a drink containing alcohol? I would then ask about substance use and, with each drug category, obtain the same information of the length of use, amount, and last use. These are essential questions to ask the patient because he could suffer from withdrawal if the use was recent. Because cocaine can cause severe suicidal ideation during withdrawal, questions like whether A.G. had ever experienced feelings of hopelessness, depression, sadness, or suicidal thoughts should be asked. Finally, questions about maintaining sobriety should be asked, such as what are you actively doing to maintain your sobriety? This can give information on addiction that the patient has accessed. In the past, have you been in treatment for drug or alcohol addiction?

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.

Basso da Silva, A., Olschowsky, A., Wetzel, C., Josué Silva, T., & Machado Pavani, F. (2020). Understanding culture, stigma and drug as a lifestyle in the life of people living in the streets. Revista Ciência & Saúde Coletiva, 25(10), 3713–3721. https://doi.org/10.1590/1413-812320202510.36212018

Mabhala, M. A., Yohannes, A., & Griffith, M. (2017). Social conditions of becoming homelessness: qualitative analysis of life stories of homeless peoples. International Journal for Equity in Health, 16, 1–16. https://doi.org/10.1186/s12939-017-0646-3

Moriarty HJ, Stubbe MH, Chen L, Tester RM, Macdonald LM, Dowell AC, Dew KP, Moriarty, H. J., Stubbe, M. H., Chen, L., Tester, R. M., Macdonald, L. M., Dowell, A. C., & Dew, K. P. (2012). Challenges to alcohol and other drug discussions in the general practice consultation. Family Practice, 29(2), 213–222. https://doi.org/10.1093/fampra/cmr082

O’Donnell, P., Tierney, E., O’Carroll, A., Nurse, D., & MacFarlane, A. (2016). Exploring levers and barriers to accessing primary care for marginalised groups and identifying their priorities for primary care provision: a participatory learning and action research study. International Journal for Equity in Health, 15, 1–16. https://doi.org/10.1186/s12939-016-0487-5

Sims, M., Kershaw, K. N., Breathett, K., Jackson, E. A., Lewis, L. M., Mujahid, M. S., & Suglia, S. F. (2020). Importance of housing and cardiovascular health and well-being: A scientific statement from the American heart association. Circulation. Cardiovascular Quality and Outcomes, 13(8), e000089. https://doi.org/10.1161/HCQ.0000000000000089

Young, S., & Guo, K. L. (2020). Cultural Diversity Training: The Necessity of Cultural Competence for Health Care Providers and in Nursing Practice. The Health Care Manager, 39(2), 100–108. https://doi.org/10.1097/HCM.0000000000000294

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D .M- Week 2 Discussion

COLLAPSE

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Main Discussion Post

In this week’s case study, I have been assigned AG, a 54-year-old Caucasian male patient seeking to establish care following an alcohol withdrawal-induced seizure and hospitalization. Additionally, this patient has a history of hypertension and cocaine abuse, is out of their Amlodipine 10 mg prescription, and is reportedly homeless, living in a local homeless shelter. This patient reports they are currently not drinking alcohol or using cocaine and are smoking cigarettes to manage their stress from not drinking. The goal of this discussion post is to identify and discuss the specific diversity and cultural considerations for AG, indicate particular risk assessment tools and communication strategies sensitive to their background, and craft 5 target questions to begin constructing their health history. Ball et al. (2019) emphasize the importance of healthcare providers weaving together cultural competence and patient-centered care to create a common ground for a whole person with unique needs. Utilizing the RESPECT model as a biopsychosocial approach encapsulates all patient needs, allowing for rapport, trust, and patient-specific education to occur (Ball et al., 2019). 

 

Assessment Strategy 

 

Evidence shows that healthcare providers should prioritize the following considerations particularly for homeless patients: “delivering trauma-informed and person-centered care, linking patients to comprehensive primary care and engaging interdisciplinary community-based services” (Liu & Hwang, 2021). Using this as the framework for my interview, I would first employ the Behavioral Risk Factor Surveillance System (BRFSS) questionnaire to ascertain this patient’s current health-related quality of life and overall readiness for change concerning high-risk lifestyle decisions (Cole et al., 2020; Jafry et al., 2021). The BRFSS allows the patient to self-endorse responses concerning smoking cigarettes, using drugs, drinking alcohol, unprotected/unsafe intercourse, dietary choices, safety, and physical activity scoring (Cole et al., 2020). Determining an initial baseline score concerning these topics would allow a plain language starting point to discuss and monitor particular activities. Understanding how receptive AG is to maintaining cessation from drug and alcohol abuse is paramount to his future and safety. Finding this common ground during the interview is a seemingly effective first step in the RESPECT model (Ball et al., 2019). 

 

Interview Content

 

The social separation experienced by individuals in the homeless population has been documented as a risk factor that increases stress and anxiety, high-risk lifestyle choices, and higher incidences of mental health disorders (Jafry et al., 2021). Keeping this in mind, the priorities of my interview would be determining a clear social history, presence of family/social support system, previous medical management history, and access to healthcare resources (Cole et al., 2020; Liu & Hwang, 2021). The following open-ended questions would be asked to begin determining this information: 

 

1. Tell me what a normal day looks like for you, AG?

This question would reveal a rich patient-endorsed response regarding several topics of interest. Any mention of family, friends, transportation, recent social events such as loss of employment, death of a loved one, or financial stress are important pieces of information to investigate further to assess quality of life. Likewise, any statements that indicate negative events or individuals would assist in assessing patient safety and concerns. Maintaining an empathetic and supportive demeanor during this conversation is vital to continue cultural competence (Ball et al., 2019). 

 

2. Prior to your recent hospital stay, when was the last time you saw a Doctor? 

It is entirely unknown if this patient is well-established with another healthcare provider, and/or is newly relocated to the area. Determining if any primary care has been previously started could give insight into previous medical history, procedures, medication regimens, or treatments (Liu & Hwang, 2021). 

 

3. I see you are out of your blood pressure medication prescription, how long have you been taking that? 

Given the past medical history of hypertension, this prescription may have been long-term, or recently prescribed during his hospitalization. Understanding if this medication is optimized for this patient’s condition would be necessary prior to investigating avenues for a refill. Liu and Hwang (2021) indicate that involving appropriate resources such as social work, case management, and community health programs for a region can assist in ensuring homeless patients are able to maintain prescription medication supplies. 

 

4. Tell me about some health concerns that you currently have, AG?

Depending upon the presence or absence of previous primary care, this patient may not have any concerns or knowledge of needs at this time. Opening this question is a great avenue to mention preventative measures to determine a current state of health. Recent vital signs, lab work, colon screening, focus head-to-toe assessment since hospitalization, prostate health, and dietary information are all important pieces of information for a male patient of AG’s age (Cole et al., 2020). It is within these findings that additional education and recommendation can occur. 

 

5. What are some things about yourself you would like me to know, AG? 

Shifting the focus from entirely health-related information, this question gives the patient an opportunity to share any piece of their story they are comfortable with disclosing. Displaying the humility to listen to the patient fits directly into the RESPECT model’s Support and Partnership intention (Ball et al., 2019). Statements made by the patient here could also reveal more regarding their overall demeanor, mental health/stability, education level, and willingness/ability to improve current lifestyle choices. 

 

Put frankly, 5 questions are simply not enough to appropriately determine the full spectrum of needs and current health of a patient with this snapshot of information. The above-explained questions fulfill what I deem to be the priority needs based on the available literature and course text prompts. Obviously, in a real-world scenario, these questions would offer an effective starting point, but incorporating case management, community resources, and completing a head-to-toe assessment would all be appropriate for this patient. Based on the risk assessment, physical assessment findings, and the patient’s willingness to learn, culturally appropriate education strategies and a plan of care could be initiated. 

 

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.). St. Louis, MO: Elsevier Mosby.

 

Cole, A. B., Hébert, E. T., Reitzel, L. R., Carroll, D. M., & Businelle, M. S. (2020). Health Risk Factors in American Indian and Non-Hispanic White Homeless Adults. American Journal of Health Behavior, 44(5), 631–641. https://doi.org/10.5993/AJHB.44.5.7

 

Jafry, M. Z., Martinez, J., Chen, T. A., Businelle, M. S., Kendzor, D. E., & Reitzel, L. R. (2021). Perceived Social Support Attenuates the Association between Stress and Health-Related Quality of Life among Adults Experiencing Homelessness. International Journal of Environmental Research and Public Health, 18(20). https://doi.org/10.3390/ijerph182010713

Liu, M., & Hwang, S. (2021) Health care for homeless people. Nat Rev Dis Primers, 7, (5). https://doi.org/10.1038/s41572-020-00241-2

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