Chapter 13: Cultural Diversity and Community Health Nursing

If a nurse is considered culturally competent in the community he/she needs to understand

what about the members of the community they work with?

Their lifestyle, value system, and health and illness behaviors of diverse individuals,
families, groups, and communities.

The national health targets for Healthy People 2020 incorporates the governments initiative to:

Eliminate racial and ethnic disparities in health

Increase the quality and years of healthy life for all Americans

Focusing on ways to close the gaps in health outcomes.

Cancer mortality rates - 35% higher in black Americans than whites

Transcultural Nursing

Madeleine Leininger, a nurse anthropologist, coined the term transcultural nursing and
defined it as a formal area of study and practice focused on a comparative analysis of
different cultures and subcultures in the world with respect to cultural care, health and
illness beliefs, values, and practices with the goal of using this knowledge to provide
culture-specific and culture-universal nursing care to people.

Culture specific what is different

Culture universal what is the similar

Value refers to a desirable or undesirable state of affairs.

Value universal feature of all cultures, types and expression differ widely.

Norms are the rules by which human behavior is governed and the result of the cultural values
held by the group which specify appropriate and inappropriate behavior

Four Basic Characteristics of Culture (know this)

1. It is learned from birth through language & socialization.

2. It is shared by all members of the same cultural group.

3. It is adapted to specific conditions related to environmental & technical factors &

availability of natural resources.

4. It is dynamic.

Regularity of food consumption (be careful with assuming all people eat three meals a day DO
NOT instruct someone from a different culture to take their pills with their meals or tell them to
take their pills 3 times a day with meals you may end up with a patient overdosing
themselves).

If you discover a nurse has incorrectly instructed a patient from different culture to take
their pills around meal time, a suggested method of assessing the patients use of
medication would be to ask: Can you tell me what times during the day you and your
family eat?

What is cultural imposition? - occurs when someone assumes the pts. beliefs, values, and
patterns of behavior are identical to their own.

Beware of cultural stereotyping: Which is the tendency to view individuals of common cultural
backgrounds similarly including assumption of food preferences. You may be surprised how
different the diet is!

Religious beliefs may influence the clients explanation of the cause of illness, perception of its
severity, and choice of healer, and source of consolation, and ability to make scheduled
appointments.

Gain a general understanding of religious calendars.

Know the customary days of religious worship, what are they?

Protestants usually worship on Sundays; Muslims day of worship is from sunset

Thursday to sunset on Friday; and Jews and Seventh-Day Adventists holy day is from
sunset on Friday to sunset on Saturday.

For what culture would it be a problem for a nurse to schedule an appt. on a Friday
morning at 10:00 a.m.? Why would the patient no-show for this appt.?

Nurse-Client Relationship - First impressions count - to ensure a mutually respectful

relationship, the nurse should introduce himself or herself and indicate how the client should
refer to the nurse (i.e., by first name, last name, or title). Having done so, the nurse should ask
the client to do the same. This enables the nurse to address the client in a manner that is
culturally appropriate and could avoid embarrassment in the future.

Language - When caring for clients who do not speak English, the nurse should:

Use a bilingual trained interpreter who knows interpreting techniques, has a health care
background, and understands patients rights and who is knowledgeable about cultural
beliefs and health practices. Do not use relatives or friends of a client - this violates
confidentiality and there is the possibility of miscommunication resulting form

unfamiliarity with medical terminology, clinical procedures, and medical ethics.

Consider gender also.

Disease causation may be viewed from three major perspectives (know the 3 perspectives and
examples):

Biomedical (i.e., sometimes used synonymously with the term scientific germ theory
all life is reduced to parts and the human person can be reduced to mind, body, & spirit)

Naturalistic (i.e., sometimes used synonymously with the term holistic - laws of nature
create imbalance, chaos, and disease), view most commonly held with Native
Americans and Asians - yin-yang theory,

Yin = female/ negative forces (e.g., emptiness, darkness, and cold)

Yang = male/ positive (e.g., warmth and fullness).

Yin foods are cold / yang foods are hot

Cold foods are eaten when one has a hot illness

Hot foods are eaten when one has a cold illness

Magicoreligious good vs. evil

Use of voodoo or witchcraft (some Caribbean countries)

Faith healing

Nurses need to understand the role and value of folk or religious healers. When
a client shares that he/she has visited a folk/religious healer, ask them what
happened during the visit.

Faith healers include, but are not limited to: Curandero (male folk healer) /
Curandera (female folk healer) / Spiritualist / Yerbo (herbalist)

The nurse and client use cultural negotiation to attempt to work out a solution with a goal to
reduce conflict and promote cooperation. The nurse asks the client to explain his/her rational
Can you tell me what your understanding of . . . is (this shows the client that the nurse is
accepting of his /her beliefs). The nurse can then provide scientific information while
acknowledging that the client may hold different views. If the client's perspective indicates that
behaviors would be helpful, positive, adaptive, or neutral in effect, the nurse should include
these in the plan of care. However, if the clients perspective would result in behaviors that may
be harmful, negative, or maladaptive, the nurse should attempt to shift the clients perspective
to that of the practitioner.

An example would be a middle aged Hispanic man coming to see the doctor for severe
right lower quadrant pain. Upon entry into the examination room, the man
immediately shares with the nurse that he feels God has caused him this pain because
he recently cheated on his wife with another woman. The nurse should accept his
beliefs, but explain that he needs further follow-up and treatment.

Clients may have a condition that is culturally defined, known as a culture-bound syndrome.
Some of these conditions have no equal from a biomedical or scientific perspective, but others,
such as anorexia nervosa and bulimia, are examples of health problems found primarily among
White members of a dominant U.S. cultural group.

Chapter 14: Environmental Health

So, what is an important goal of a community health nurse?

o Helping communities become more aware of how the environment affects their health
and helping them take actions to make needed changes in the environment is an
important goal of community health nursing.
Is it easy or difficulty get people motivated to work on environmental problems?
o it is a challenge to get people motivated to work on environmental problems
Nurses must realize that chronic environmental problems are rarely addressed effectively!
What do people respond to?
o Acute crises with dramatic media coverage (such as hurricanes or earthquakes, current
Ebola issue in Texas), but ongoing consistent pressure is needed to ensure day-to-day
environmental integrity.
Critical social theory (CST) is a way of thinking upstream.
o It uses an approach that raises questions about:
oppressive situations
involves community members in the definition and solution of problems
(facilitates group action)
facilitates interventions that reduce health-damaging effects of environments.
o What should a nurse make sure to do when he/she is collecting a health assessment?
Ask critical questions about clients work and home environments
Need to look for health hazards
o Remember critical social theory focuses on oppression and facilitates group action.
Environmental health histories should be obtained for both adults and children, although the
relationship between the environment and children's health is frequently overlooked. Also,
although frequently overlooked, a parent's occupational exposures may put the child at risk for
particular health problems. This slide and the next provide screening questions.
o Environmental screening questions to ask an adult: Important questions - should be
asked during an annual physical - often overlooked!

The I PREPARE mnemonic cues the provider to:

o I - "Investigate potential exposures; ask questions related to:
o P -"Present work,
o R - "Residence,
o E - "Environmental concerns,
o P - "Past work," and
o A - "Activities;"
o provide - R "Referrals and resources;
o E - "Educate" the patient by reviewing a checklist of strategies to prevent or minimize
exposures.
I PREPARE is a great tool to remember when completing an environmental exposure
assessment.
Living pattern risks are NOT individual lifestyle choices, (i.e., eating a high-fat diet or substance
abuse), but reflect population exposure to environmental conditions that are affected by mass
culture, social practices, ethnic customs, and technology.
o What are some examples of Living Pattern Risks?
drunk driving
second hand smoke
noise exposure
urban crowding
technological hazards
What is environmental racism it is discriminatory land use policy that causes the poor and
racial minorities to live in close proximity to contamination from industrialization
What is sick building syndrome?
o Poor housing can spread infectious disease and can contribute to cardiovascular and
respiratory disorders, cancer, allergies, and mental illnesses.
o The term sick building syndrome has been used to describe instances in which buildings
and homes cause toxic symptoms in occupants due to building materials, poor
ventilation, substances in furniture and carpeting, toxic mold, and/or cleaning agents
(Karis example).Building occupants complain of symptoms associated with acute
discomfort,
o One of the major challenges with complete removal of toxic elements from our
buildings is the economic hardship that industry, government, business, and multidwelling owners would face if they were forced to reduce concentrations of toxic
elements.
REMEMBER: Clean, Separate, Cook, Chill
Several environmental health problems are related to waste control and include:
o a. Use of non-biodegradable plastics
o b. Lack of efficient and affordable recycling programs

Poorly designed solid waste dumps - accumulate methane gas a byproduct of

decomposing organic waste. Without proper venting, this volatile gas can move
through soil and cause fires and explosions in nearby areas.
o d. Inadequate sewage systems
o e. Industrial dumping of toxic wastes/Illegal dumping of toxic wastes
o g. Transport and storage of hazardous waste
o h. Lack of enforcement of environmental protection legislation
Millions of Americans are exposed to dangerous levels of radon gas in their homes, schools, and
work places every day. Radon contamination is the second leading cause of lung cancer
mortality in the United States, contributing to an estimated 15,000 to 20,000 deaths of this
disease each year. Radon seeping through basement walls, pipes, and foundation cracks that is
trapped in buildings with inadequate ventilation is the most common cause of radiation
exposure.
Unfortunately, the EPAs momentum slowed in the 1980s, with policies being reversed and
regulation losing its funding. This trend has continued. The EPA sets rules but lacks resources to
accomplish the goals.
Form coalitions
o By initiating dialogue and building a strong base of collective support, nurses join with
communities to eliminate hazards and improve public health. Nurses can approach
existing community organizations, churches, and family and friendship networks to help
mobilize aggregate members who have not previously socialized or acted together to
produce social change. Community coalitions can actually realize change when facing
an issue r/t an environmental challenge from a large corporation. Using collective
strategies
o Also engage in Participatory Action Research (PAC) the goal is for nurses, community
members, and other resource people to work together in identifying environmental
health problems, designing the studies, collecting and analyzing the data, disseminating
the results, and posing solutions to the problems. By participating in PAC, open
discussion and debate occurs that intensifies a community's consciousness of healthimpairing environmental constraints.

Chapter 15: Globalization and International Health

Human health and its influence on every aspect of life are central to the global agenda.
Community public health nurses must be aware of forces that threaten health in the global
community.
Any infectious disease is just a plane ride away, thus the reason nurses need to be familiar with
infectious disease that occur elsewhere in the world!
Globalization is the process of increasing social and economic dependence and integration as
capital, goods, persons, concepts, images, ideas, and values cross state boundaries is
inextricably linked to the benefits and challenges of our time.

An ever increasing population is one of the biggest threats to developing countries to being able
to grown economically and make life better for their citizens
Pressures from population growth are also felt in both developing and developed countries.
o Feeding a population becomes problematic in developing countries when famine,
international trade problems, or war occur.
o Malnutrition, disease, or death are often the outcomes.
Over 50% live in China, India, the former Soviet Union, the U.S. & Indonesia; and over 40% are
children; 12% are elderly
Disease patterns vary throughout the world; therefore primary causes of mortality
differ in developed vs. developing countries
o Developed countries d/t chronic diseases
o Developing countries d/t violence, communicable disease, and malnutrition
As a developed country lessen the mortality rates r/t sanitation, nutrition, lack of medical care
access, and immunization coverage, many experience an epidemiological transition from an
infectious disease profile to a chronic disease profile and see an increasing # of middle-aged
and elderly adults.
The infectious diseases that contribute to high rates of mortality in developing countries are:
o AIDS
o Tuberculosis (TB)
o Endemic malaria
o Hepatitis B
o Rheumatic heart disease
o Parasitic infection
o Dengue fever
The Four primary challenges to international health (TB, malaria, tobacco, and Aids).
o For example, the estimated male-female ratio of HIV infections in North America is 5:2,
what do you think it is in Africa? The ratio is 1:1. Urbanization and migration play a role
in the spread of AIDS. HIV threatens more lives as more people migrate into the world's
largest cities to find employment. In nations with high rates of AIDS, there is high birth
rate, but life expectancy is only what? 35 to 40 years. Substantial reductions in HIV
seroprevalence occurred after several countries deployed ABC (Abstinence, Be
faithful, Condom use) campaign.
o Who do tobacco companies target? Tobacco companies have targeted children and
international customers since the U.S. companies have experienced losses. Tobacco
control is a critical component of the international health care agenda. By 2020, an
estimated 1 in 7 deaths will be tobacco related. A global commitment to tobacco control
can avert millions of premature deaths in the next half century.
With primary health care as its main focus, the WHO promotes seven elements of care:
o health education regarding disease prevention and cure
o proper food supply and nutrition
o adequate supply of safe drinking water and sanitation

o maternal and child health care

o Immunizations
o control of endemic diseases
o provision of essential drugs.
o Promotion of safe sex practices is NOT on the list of 7.
Nongovernmental organizations (NGOs) such as the Bill and Melinda Gates Foundation and
the Carter Center.
KNOW what the Alma-Ata is:
o The Alma-Ata conference on primary health held in 1979 in the USSR expressed as a
goal Health for all by the year 2000, this goal expressed the need for urgent action by
all governments. The goal was extended to 2010 again without attainment.
o Alma-Atas concept of primary health care stresses:
Health as a fundamental human right for individuals, families, and communities
Unacceptability of the gross inequalities and disparities in health status
Importance of community involvement
Active role of all sectors
Primary health care is:
o Essential to support a healthy life.
o Involves access, availability, service delivery, community participation and the citizens
right to health care.
Primary care
o Refers to first line or point-of-access medical and nursing care controlled by providers
and focused on the individual.
Nurses are health cares most valuable assets!
A great service learning opportunity for students is to volunteer at a free clinic assisting with the
collection of health assessment data. You really learn about the challenges members of your
community face regarding access to healthcare and life stressors. This type of service learning
helps the student to integrate meaningful community service with instruction and reflection to
enrich the learning experience, teach civic responsibility, and strengthen communities.

Chapter 16: Child and Adolescent Health

Teen birth rate falls to another historic low

Birth as a teen results in poverty in most cases for both mom and baby.
Infant mortality is the most important indicator of a community's and/or nation's health and
welfare.
As an indicator of worldwide health status, the United States ranks poorly, lagging behind many
nations
o What countries have best infant outcomes Monaco, Japan, Bermuda, Norway,
Singapore, Sweden (top 6), The U.S. is much LOWER on the rating scale lower than even
Cuba (4.7 deaths/1000 live births) , Croatia and Bosnia have better rates than the U.S. at

(5.84/5.87) the U.S. rate is 6.17 deaths/1000 live births). The worst country is
Afghanistan (117.23 deaths/1000 live births).
o Despite these efforts, there are still disparities between racial and ethnic populations.
Prematurity is a key risk factor for infant mortality. When assessing a newborns health, two of
the most important assessment factors are
o 1. Birth weight
o 2. length of gestation
Factors associated with preterm birth and low birth weight include:
o minority status black infants die at twice the rate than white infants
o maternal age of less than 17 years and over 35 years
o chronic health problems such as
diabetes mellitus hypertension and obesity, lack of prenatal care, low
socioeconomic status, unhealthy maternal habits, poor nutrition, alcohol and
drug use, and cigarette smoking
Half of all pregnancies are unintended! So if you work in OB dont be surprised if a woman is
initially upset when she learns that she is pregnant.
Remember in Wisconsin - Medicaid covers prenatal care for low-income pregnant women and
infants.
If no woman smoked during pregnancy the rate of low-weight infants would decrease by 25%
Infant mortality rate for babies born to smokers is ~ 70% > than nonsmokers
Alcohol abuse during pregnancy is the primary preventable cause of mental retardation in
children
Like alcohol, illicit drugs can also cause permanent harm to an unborn baby!
After the first year of life accidental injury is the leading cause of death (e.g., motor vehicle
accidents, drowning, burning, and suffocation)
o Assure proper car seat use
Another major contributor to childhood accidental injury is head injury d/t cycling,
skateboarding, & inline skating
o A fall from as little as two feet can cause traumatic brain injury
o Assure proper helmet use
This is an area where school nurses can make an impact by educating grade school, middle
school and high school students about the risk for TBI from various sports activities.
Lead poisoning is preventable
o It causes childhood death, mental retardation, cognitive and behavioral problems,
decreased growth, renal disease, GI problems, hearing deficit, cardiovascular effects
(B/P), reproductive toxicity, and may cause irreversible neurologic damage
o Signs and symptoms are difficult to recognize. When working in the community, be alert
to an increased risk of lead toxicity for persons living in dwellings built before 1970
when lead was removed from paint.
Now, consider a child who is ill, hungry, cannot see the chalk/white board, cannot hear, has a
learning disability, is living with abuse, fearing their safety at home or in school how well are

they learning? A childs life experiences beginning at conception through adolescence will
substantially impact their futures.
Untreated dental decay is the most preventable chronic disease in the US
In their struggle to gain independence and with their sense of immortality, many adolescents
engage in high risk behaviors that threaten their health, these high risk behaviors include:
o Tobacco, alcohol, and drug abuse serious/long lasting health & societal consequences
o Early and unprotected sexual activity leads to pregnancy and STIs
o Unsafe driving
o Participation in delinquent and violent activities
o It is not surprising that the leading cause of death for those aged 15 to 24 years is
unintentional injury.
Most commonly used illicit drug is marijuana
Participation in school-based, community-based, and church or faith-based activities lowers the
risk for alcohol, tobacco, and illicit drug use.
POVERTY is the greatest threat to child and adolescent health
Startling facts r/t Health Disparities:
o 82% of children whose parents do not have a high school education live in low-income
families.
o Women with less than 12 years of education are almost 10 times more likely to smoke
during
pregnancy than mothers with 16 years of education.
Medicaid and Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) programs
o Medicaid has greatly increased access to preventive health care for pregnant women,
infants, and children. State and federal governments jointly finance Medicaid, which has
become a primary payer for prenatal care and deliveries.
There are barriers to Medicaid use though, they include:
Increasing numbers of physicians unwilling to take Medicaid patients
Lengthy application forms and eligibility determination process
The stigma associated with being on welfare
Unfriendly, overcrowded, and uncomfortable waiting rooms and public
clinics
State Childrens Health Insurance Program (SCHIP)
o SCHIP provides health care coverage for children whose families have incomes above
those that would make the eligible for Medicaid but who do not receive insurance
through employment.
Special Supplemental Nutrition program for Women, Infants, and Children (WIC): Provides
highly nutritious foods, nutrition education and counseling, and screening and referral to lowincome pregnant and breast-feeding mothers, their infants, and their children under age 5 each
year.
Head Start: A comprehensive, federally funded early childhood program for low-income children
aged 3 to 5 years, Head Start aims to increase the school readiness of young children in lowincome families. They provide educational opportunities and medical, dental, mental health,

nutritional, and social services. They strongly emphasize parental involvement on a voluntary or
paid-staff basis.
o The goal of Head Start is to help children overcome the effects of poverty.
Chapter 7: Womens Health

Beginning in the 1970s, the Womens movement called for the reform of systems affecting
women's health. Women were encouraged to become involved as consumers of health services
& establishers of health policy.
The #1 killer of women is Heart Disease! Cardiovascular Disease (CVD)
o About 10% of women less than 60 years of age have some form of cardiovascular
disease
o Cardio vascular disease (CVD) more common among women of color
Rate increases to 1 in 3 after age 65
After age 65, a woman is twice as likely to die of heart disease
o One of the biggest reasons is that women die more frequently than men from CVD is
they receive less prevention (i.e.,cholesterol screening, use of aspirin or statin drugs to
lower cholesterol) and present their symptoms differently many times a woman will
complain of a nagging back ache and not consider CVD when men have crushing chest
pain
Why do you think that ectopic pregnancy has increased dramatically during the past two
decades particularly for nonwhite teenagers? Ectopic pregnancy associated with STIs non
white teens usually have less access to health care.
Women are more likely than men to be disabled from chronic conditions such as arthritis and
hypertension. Women are also more likely to have functional limitations.
The most frequent mental health condition of women is depression.
o Women experience depression at 2 to 3 xs the rate of men.
o Assess for the following:
Common symptoms include depressed mood, apathy (i.e., helpless, hopeless,
worthless) lose interest in everything, lack of appetite, anxiety, irritability, cant
sleep & thoughts of death and suicide
Unique to women are atypical symptoms:
Anxiety
Increased appetite
Weight gain
Somatic complaints
Increased rates of comorbid conditions
Women are more likely to attempt suicide, but less likely to succeed
Employment and Wages
o Poverty is a womens issue. Nearly six in ten poor adults are women, and more than half
of all poor children live in families headed by women.

Poverty rates - especially high for single female heads of household, women of color, &
elderly women living alone.
Common Acute Illness in women include UTI & dysuria, disease of the reproductive tract, mental
disorders and stress, & chronic diseases
Why are women more prone to higher rates of UTIs?
o Differences in anatomy (women have a shorter space from urethra to bladder) which
enhance the exposure to potential uropathogens to colonize the urinary tract, poor
hygiene practices after toileting, and genetics (some women are more prone)
Osteoporosis - major disorder affecting women! Most serious complication - hip fracture
o First year after hip fracture ~ 17% of women die
What is the recommended intake for women over age 50 r/t Vitamin D? 1200 mg Ca, 600 IU Vit.
D if levels normal
Disabilities in women are commonly from acute problems such as dysmenorrhea, which affects
approximately 50% to 80% of the female population between ages 15 and 24 years making it the
greatest single cause of absenteeism from school and work among young women.
Civil Rights Act (1964)
o Title VII of the Civil Rights Act of 1964 prohibits discrimination based on sex, race, color,
religion, ornational origin in determining employment eligibility or termination, wages,
and fringe benefits and was amended to prohibit discrimination against pregnant
women or conditions involving childbirth or pregnancy making it unlawful for employers
to refuse to hire, employ, or promote a woman because she is pregnant.
o Sexual harassment is also a violation of the Civil Rights Act.
Family and Medical Leave Act (1993)
o Allows an employee a minimum provision of 12 weeks unpaid leave each year for family
and medical reasons such as personal illness; an ill child, parent, or spouse; or the birth
or adoption of a child.
Levels of Prevention and Womens Health
o A. Primary Prevention (preventing the disease from occurring).
Recognize risk for disease and target health care behaviors to reduce risk.
Not smoking, eating a nutritious diet, following safe sex practice, avoiding drugs,
limiting alcohol, staying physically active and family planning are just a few
examples.
o B. Secondary Prevention (detecting the disease once it has begun but before it appears
clinically).
Examples of this level of prevention include routine screening for cervical
cancer, STIs, breast self-exams, and mammograms.
o C. Tertiary Prevention (seeks to stop further complications after a disease has become
clinically evident.)
Education and resource utilization.
Roles of the Community Health Nurse

Educator: The nurse encounters many opportunities for teaching. It is important for the
nurse to attempt to gain trust and be sensitive to any cultural issues present to be
successful in this role. The nurse must also be aware of the emotional and physical state
of the client and consider this in planning.
Many community health nurses has been challenged to use currently developed theoretical
models in their clinical practice because they were developed with a middle class focus, not a
low income focus.

Chapter 18: Mens Health

Heart disease remains the leading cause of death among men

While males are __ times more likely than females to die by suicide, females attempt suicide
__times as often as males.
Males over age 85 are 11 times more likely to die as a result of suicide.
Race / ethnic background are also factors - higher death rates occur among black and Hispanic
men, except when considering suicide:
o 2010 suicide rates for males:
Whites - 14.1
American Indians and Alaskan Natives - 11.0
Asians and Pacific Islanders - 6.2
Hispanics 5.9
Blacks - 5.1
Despite the differences in mortality, men tend to perceive themselves to be in better health
than do women
Men tend to rate their health as excellent or very good vs. a womans fair to poor
Although women tend to have higher morbidity overall, men have lower morbidity rates for
most illnesses but higher mortality rates.
Please focus on the Unintentional injuries categories, suicide, homicides and unintentional
accidents notice that the #s for men are double when compared to women.
Although men are less commonly hospitalized, they typically require longer lengths of stay
(LOS) when hospitalized until the age of 65, where a womans LOS exceeds a mans
Mental Health Care
o Admission for serious mental disease accounts for the largest number of hospital
admissions for men aged 45-74.
o Women of same age (45-74) more likely to be admitted for heart disease
Higher miscarriage, stillbirth and male infant deaths during the first six months reduces this ratio
Males are at greater risk for premature birth, higher rates of RDS, and infectious disease in
infancy d/t male hormones impact on the developing lungs, brain, and possibly the immune
system
Impact of sex chromosome-linked diseases (can you think of a couple of these? i.e., hemophilia
and certain types of muscular dystrophy) more common among males than females.
Men's higher testosterone levels contribute to men's lower HDL levels.

Females have lower rates of early onset of heart disease, probably because of the protective
effects of estrogen.
A mans masculinity gets in the way of health promotion behaviors! Men tend to ignore
symptoms or refuse to see them as symptoms of illness and act tough.
In the United States - society emphasizes assertiveness, restricted emotional display (men talk
less about health problems, often times during intake health assessments, they struggle to
articulate their symptoms when they do not have experience with the medical system), concern
for power, and reckless behavior in males. Pursuit of these masculinized attributes results in
increase risks in work, leisure, and lifestyle.
Some men think engaging in health promoting behaviors = weakness, as a result men:
Men experience higher numbers of occupational injuries work-related fatalities.
o ___% of occupational injuries and ___% of work related fatalities
Popular male sports place them at high risk for injury, but men do engage in exercise that is
beneficial to health more often than women do
o Men less likely to use protective devices
Men are more likely than women to abuse drugs, consume alcohol, and participate in violent
crimes.
Illness orientation is defined as the ability to note symptoms and take appropriate action this
too differs between the sexes.
Boys and men are socialized to ignore symptoms and toughen up rather than seek health care.
Currently HCPs do not receive gender specific training that enables them to focus on mens
health needs, without this specialty, gender disparity will continue
Access to care
o Health care has focused on maintaining an effective workforce, focus needs to shift to
ensure a holistic perspective
o Many private insurance companies reimburse more for a diagnosed condition and less
for preventive care, need to adjust this reimbursement focus on prevention, education,
& counseling
o Time factor care available between 9-5, Monday-Friday, many men cannot take time
off from work d/t loss of income or stigmatization
Lack of health promotion
o Financial resources are invested in traditional disease curative care rather than health
promotion action.
o To ensure social justice, nurses need to work toward the dev. of health policies that
address health for all.
Which single action has been most influential in changing mens health behaviors?
o Legislative action
Health behaviors associated with the greatest change in a positive direction
have been those influenced by legislative action (e.g., seat belt use, use of
smoke detectors, and drunk driving).
Blood pressure check:

o Every 2 years, if < 120/80

o If 120-139/80-89 Hg or screen annually
o Higher than 140/90 consult with MD asap
Prostate examination: Every year after age 50 for men with no family history, start screening at
age 45 for men at high risk of developing prostate cancer (African Americans and men who have
a first-degree relative (father, brother, or son) diagnosed with prostate cancer at an early age younger than age 65).
Strategies to talk with men about their health:
o When attempting to open a door to talk to a man about his health it is suggested the
nurse focus three topics (physical activities, leisure time, and self care)
o What are your usual physical activities, and how do you take care of yourself while
doing that?

Chapter 19: Senior Health

Functional age refers to functioning and the ability to perform activities of daily living such as
bathing and grooming and instrumental activities of daily living such as cooking and shopping.
Functional age is a much better measure of age than chronological age
Stochastic theories explain aging as events that occur randomly and accumulate over time.
o Error Theory: Errors in protein synthesis over time result in impaired cellular function.
o Free Radical Theory: Reactive molecules that possess a free electron cause damage to
protein membranes, enzymes, and DNA.
o Wear and Tear Theory: Man is similar to a machine that wears out over time.
Nonstochastic theories - predetermined aging view Programmed Theory: Cells are programmed
to divide only a specific number of times, and this number is proportional to species life span.
The three classic psychosocial theories of aging are behavioristic and examine how one
experiences late life.
o Disengagement theory - aging is an inevitable mutual withdrawal or disengagement,
resulting in decreased interaction between the aging person and others.
o Activity theory posits that activity is necessary to maintain a persons life satisfaction
and a positive self-concept.
o 3. Continuity theory suggests that a person continues through life in a similar fashion as
in previous years.
Aging is not so much r/t to your genes, but your what? lifestyle - the latest scientific thinking
suggests that up to 70% of aging process is related to how you live. Perhaps as little as 30% is
genetically determined.
93% of older adults typically prefer to age in place or live in their own home for as long as
possible:
o However, 2% of the Medicare population age 65 and over resided in community housing
and approximately 5% resided in long-term care facilities
What is the primary income for most older adults?

Social Security constituted 90% or more of the income received by 36% of beneficiaries
(23% of married couples and 46% of non-married beneficiaries). Can you imagine trying
to live only on a SS check?
The highest poverty rates were experienced among older Hispanic women (38.8%) who lived
alone and also by older Black women (32.2%) who lived alone.
Retirement often brings with it a change in social status and possibly income level
o Especially difficult for those whose self-concept is related to job status.
o If married, the spouse must also adjust to the changes related to retirement. In some
cases, more difficult for the wife!
o For elders who have no hobbies/interests, extra leisure time often a source of boredom,
which can be relieved by hobbies or outside interests.
Raising grandchildren - many older adults are faced with the responsibility of raising their
grandchildren, often without the presence of the grandchildrens parents.
o Antecedents to children being raised by grandparents include neglect related to
parental substance abuse, abandonment, emotional and physical abuse, parental death,
mental and physical illness, incarceration, teen pregnancy, and grandparents assisting
adult children who work or attend school.
o This responsibility creates clinically significant levels of stress that may require
professional counseling and assistance with coping.
A quick & easy way to assess for nutritional health is using the mnemonic DETERMINE, it reviews
warning signs and risk factors of poor nutritional health.
o Disease
o Eating poorly
o Tooth loss/mouth pain
o Economic hardship
o Reduced social contact
o Multiple medications
o Involuntary weight loss/gain
o Need assistance in self-care
o Elder years (>80 years old)
a roughly fivefold increased adjusted MACE rate compared with people not receiving an
antipsychotic. The relative risk was highest during the first 30 days in patients on the highest
haloperidol dosages, 2 mg/day or more, who had a 10-fold increased MACE rate.
Cataracts are the leading cause, as well as the most reversible cause, of visual impairment in
older adults. When you think cataract think clouding. A cataract is a clouding of the normally
clear lens of ones eye. It is similar to trying to see through a frosted or fogged-up window.
The leading cause of death due to unintentional injuries for seniors is fall-related injuries.
Seniors who experience a hip fracture are more likely to die in the first year following that
injury.
Head injuries can cause traumatic brain injury. Traumatic brain injury results in a number of
deaths and cases of permanent disability. Elderly men have consistently accounted for about

of the number of TBI cases. Motor vehicle crashes account for 48.3%, and falls account for
18.5%.
Though seniors are generally safe drivers, they are more likely to be injured or killed in the event
of an accident. One of the quality-of-life factors that is important to seniors is the ability to
drive. This issue often causes family arguments.
Residential Fire Related Injuries - older adults are two times more likely to die in a residential
fire than the rest of the population. This risk may be attributed to reduced sensory abilities such
as smell, touch, vision, and hearing, diminished mental faculties, slower reaction time, increased
disabilities, and economic and social concerns that may prevent necessary home improvements
that could reduce risk. It is critically important for functional smoke detectors be placed in the
home, nurses should assess for their presence.
Hypothermia is a body temp. related disorder. Hypothermia is defined as a core temperature of
less than 35 Celsius. Hypothermia is the most serious of the cold stress related disorders. Other
cold stress disorders are frostbite and trench foot that occurs from long exposure to extremely
cold temperatures.
In the event of hypothermia, measures that can be taken are to remove the individual from the
cold area as soon as possible, add more clothing especially to the head (e.g., hat or scarf),
provide a warm sweetened drink (no coffee or tea), and apply mild heat to the head, neck,
chest, and groin areas using hot water bottles or warm moist towels.
Suicide - elderly account for at least 19% of all suicides with many others going unreported.
Double suicides involving spouses or partners occur most frequently among the aged.
o Elder suicide is associated with depression, for example, chronic illness, physical
impairment, unrelieved pain, financial stress, loss and grief, social isolation, and
alcoholism.
o Warning signs to watch for in the elderly are loss of interest in things or activities that
are usually found enjoyable, cutting back from social interactions, self-care, and
grooming activities, not following medical regimens, experiencing or expecting a
significant personal loss, feeling hopeless and/or worthless, putting affairs in order,
giving things away, making changes in will, and stockpiling medications or obtaining
other lethal means for committing suicide. The most significant warning sign is any
expression of intent. These warning signs need to be dealt with immediately!
Prevention activities include dispelling any myths, promoting awareness,
developing broad-based support, and reducing stigma associated with aging.
Alzheimers Disease
o One assessment tool is to have the client draw a clock. Clients with Alzheimers disease
are unable to draw a normal clock. One test for Alzheimers disease is to have them
draw a clock. Clock drawing had a sensitivity of 86.7% and a specificity of 92.7%. The
clock drawing test is an easily administered, low-cost screening tool, which is useful.
o The Patient Self-Determination Act (PSDA) is a federal law that requires health care
facilities that receive Medicare and Medicaid funds to inform patients in writing of their
rights to execute advance directives concerning end of life care. In the absence of

written advance directives, oral advance directives may be challenged legally if family
members are not in agreement about the persons wishes.
Living wills are legal documents whose purpose is to allow individuals to specify
what type of medical treatment they would or would not want if they became
incapacitated and had an irreversible terminal illness. An individual must be
competent to initiate a living will, and he or she can revoke or change it at any
time.
A durable power of attorney is a type of advance directive that authorizes
someone to act on an individuals behalf with regard to property and financial
matters. When an individual has no advance directive, is incompetent, or unable
to handle ones affairs adequately, a guardian may be appointed by the court to
direct the individuals medical treatment, housing, personal needs, finances,
and property.

Communicable Diseases
Malaria

Transmitted through bite of female mosquito

Most deaths in children five and younger
Partial immunity is developed over years of exposure and while it provides complete protection, it
does reduce the risk that malaria infection will cause severe disease
Spray clothes with permethrin to avoid mosquitos
Sprays containing DEETS on skin
Home with insecticides
Drug resistance is current issue of concern

Hand, Foot, & Mouth

Contagious viral illness (enterovirus group)

Commonly infants and young children
Starts not feeling well, overall painfull sores and skin rash on hands and feet
Complications dehydration rare- viral meningitis, encephalopathy

Chagas Disease

Insect vectors (vector bourne)

Mainly found in LA where poverty is widespread
kissing bugs
triatomine insect feces
characteristic first visible signs: skin lesions or purplish swelling of eyes
most recognized marker of acute- Romanas sign, swelling of eyelids on side of face

People can remain asymptomatic for life

Important to screen blood for

Chikunguya Fever

that which bends up; and refers to contorted posture of infected patients suffering from severe
joint pain
mosquito borne viral disease characterized by acute onset of fever and severe polyarthralgia
large outbreaks with high attack rates
GBS is a rare complication
No med or vaccine
Shares similar characteristics with dengue virus

Fifth Disease

One of 5 classical rashes associated with infections of childhood

Parvovirus B19
More common in children
Slapped cheek syndrome
Not likely contagious after rash appears
IGM can be detected for up to 3 months
Third stage aka polyarthropathy syndrome

Cholera

Acute diarrheal illness caused by infection of the intestine

John snow and epidemiology, mapping cholera from a water pump in mid 1800s
Spread from person to person through ingestion of water or food contaminated with feces
Can survive in well water for 7.5 days or give or take 2 days; can survive for 1-14 days in food and
drinks at room temp; 1-35 days in freezer
Characterized by profuse watery diarrhea, (rise water stools), vomiting, rapid heart rate, low BP,
restlessness
Fatal quick due to rapid loss of fluids and electrolytes death and shock
2 dose vaccines available; tx oral or IV hydration
IS on federal quarantine list
Risk- unsafe water, immunocompromised, living in unsanitary conditions

Chicken Pox, Shingles

Varicella roster virus

Children <12
Itchy rash spots that look like blisters accompanied by flu like symptoms

Highly contagious; for two days before rash appears and until blisters have crusted over
No evidence that virus lasts beyond 24 hours
Through air; direct contact
Risk- newborns, immunocompromised, pregnancy, steroids, adults
VARICELLA VACCINE: two vaccinations
o 12-15 mos
o booster 4-6 yrs
o kids who have had pox do not need vaccine; lifetime immunity to virus
Never give aspirin- REYES SYNDROME