DEIB Case Study: Anticipating Unique Health Risks in Clients Who Identify as LGBTQIA+ (Nursing)

by Jacquelyn McMillian-Bohler, PhD, CNM

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    00:01 Hi, I'm Jackie, let's do a case study.

    00:05 The title for the case today is anticipating unique health risks and clients who identify as LGBTQIA+.

    00:14 A nurse is in the emergency room, and she's providing care to a 15 year old adolescent female, who goes by the name of Taylor, who presented following increasing abdominal discomfort over the previous week.

    00:28 You have the nurses notes in front of you, but let's talk about them and see if we can find out some more details about Taylor.

    00:34 So the nurse completed an abdominal assessment and it was normal.

    00:38 The vital signs were within expected parameters, so that was fine.

    00:42 Taylor denies any nausea and vomiting and really hasn't had any changes in her appetite.

    00:47 The last bowel movement was normal.

    00:49 She's voiding without any difficulty.

    00:52 A urine sample was completed and that was sent to the lab.

    00:55 The health care provider also ordered an abdominal X-ray and a urinalysis.

    01:00 Further questioning for Taylor, the nurse found out that the abdominal pain is 2 out of 10.

    01:05 And we have some quotes that we need to pay attention to.

    01:08 So Taylor says, it gets worse at school.

    01:11 And the parents report that over the counter antacids were given before coming to the emergency department.

    01:17 But there wasn't any relief with that.

    01:20 When the nurse asks if Taylor is sexually active, what she says is kind of hesitant.

    01:26 And what she says is, I'm just in the girls.

    01:29 Her parents seems to be pretty embarrassed at that statement.

    01:32 And what she says is, that's just a face.

    01:35 Interesting. So now let's go back Interesting.

    01:39 So now let's go back into the chart.

    01:42 And what we find under demographics, under sex, Taylor's female, she also identifies as female.

    01:48 Remember, we want to clarify that.

    01:50 Her age is 15.

    01:51 And under her past medical history, we find that Taylor has been in the nurse's station all week.

    01:57 She doesn't report any nausea and vomiting and she denies any changes in her eating or bowel habits.

    02:03 Current medications, we always want to ask about that.

    02:06 She's taking a multivitamin and also melatonin 3mg at bedtime.

    02:10 That's usually for sleep.

    02:12 Forpsychosocial history, she lives with her primary family.

    02:16 Her parents are her biological parents, and she has two younger siblings.

    02:20 There's no history of any mental instability.

    02:23 For substance use history, she denies any drug use, no tobacco use, and no alcohol use.

    02:30 Her vital signs, 99.0 or 37.8 Celsius, that's normal.

    02:35 Respiratory rate, 16, heart rate 84, blood pressure 120/80, pulse ox all of these things are within normal limits.

    02:44 Now we have a new nurses note to review.

    02:47 So when the parent is not present, and the clients asked to change into her gown, the nurse notes that Taylor has some scarring, both new and old, that seem to be associated with self-harming.

    03:00 She notices that on Taylor's inner thighs.

    03:05 So let's think of a question that would go with that.

    03:07 So what is the priority assessment that the nurse needs to obtain when the client returns from the X ray? So think about all the things that have happened so far? What is the priority assessment? Let's look at these options and see what is the best answer.

    03:23 The first one.

    03:24 With the mother or another staff member present, collect a stool smear and send it for fecal blood test.

    03:30 The second.

    03:31 With the mother or another staff member present, perform an abdominal assessment for rebound tenderness.

    03:36 The third option.

    03:38 With the mother not present, question the client about the scarring noted on the inner thighs.

    03:43 Or the final option, discuss ordering a pregnancy test on the previously collected urine sample with the healthcare provider.

    03:51 So take a moment and really look at these and see what you think is the best answer.

    03:59 All right, let's review.

    04:01 So do we need to collect a stool sample? Well, it's important, but it's not a priority right now.

    04:11 Now with the mother or staff member present, do we need to perform another abdominal assessment to look for rebound tenderness? Maybe, but is that the most important thing so far? You've already done one abdominal assessment and it was normal.

    04:26 The third option.

    04:27 With the mother not present, question the client about the scarring on the inner thighs.

    04:33 We already know Taylor's a little hesitant about speaking about her history, especially related to her sexual history.

    04:39 And we know this might also be a sensitive topic.

    04:42 And we can ask this question without the mother present.

    04:46 Does that seem like a good answer? Yeah, it's a great answer.

    04:50 But let's look at the last one just in case.

    04:53 So discussing pregnancy tests.

    04:55 Discussing a pregnancy test might be important, but what did Taylor tell, she's into girls, so it's not likely she's pregnant unless something else has happened.

    05:05 So that's not the best option.

    05:07 So option three is the correct answer.

    05:10 So the next set of nurses notes is really telling.

    05:13 So this happens after the nurse asks about the scarring on Taylor's inner thighs.

    05:19 And what the nurse says is that, Taylor actually begins to start crying when she asks about the scarring.

    05:24 And she says, that her family doesn't really understand who she is, and that they actually hate her.

    05:31 And that she's been with the nurse because her classmates have been avoiding her since she came out.

    05:36 She's been staying with the nurse because the nurse is the only person who actually listens to her.

    05:41 She says that her stomach hurts when people make fun of her.

    05:45 And that really happens all around coming out as a lesbian.

    05:49 So this is an important note, and lets us know maybe what's really going on with Taylor.

    05:54 So based on those nurses notes, let's try the next question.

    05:59 And this example, we're going to complete the next sentence using the drop down options provided.

    06:05 Here's the sentence.

    06:06 After reviewing the assessment findings by the client, the nurse is most concerned about the clients reported _____, ______.

    06:15 Make sure you pay close attention that we want to utilize the subjective data provided by the client.

    06:22 That's key.

    06:23 Let's look at the options for option one.

    06:26 Statements about the family: Scarring noted on the inner thighs, identification as a lesbian, stomach pain, or social isolation at school.

    06:37 Take a moment and think about what might be the best answer for option one.

    06:45 Okay, let's go through the options.

    06:48 Statements about the family.

    06:50 Well, those quotes were pretty heartbreaking when Taylor reported what was happening to her with her family.

    06:55 And we know that teens who identify as LGBTQIA+ are more likely to be rejected by their parents and caregivers.

    07:04 And that kind of activity can really place them at higher risk for both mental health issues, and also physical health issues, especially when they become young adults around the ages of 21 to 25.

    07:16 So this is certainly something we would absolutely want to follow up on.

    07:19 Let's see what else.

    07:22 The scarring noted on thighs.

    07:24 Was this something that was important? We didn't really get a great answer about We didn't really get a great answer about what was going on.

    07:31 But we definitely need to explore this one.

    07:34 Identification as a lesbian and social isolation at school.

    07:39 Well, these are certainly important.

    07:40 But let's think about it.

    07:41 We're looking for priority interventions and we're thinking about where we are we're in the ER.

    07:47 So let's think about what we can do.

    07:49 So they're important, but they may not be more important than the statements about the family or the scarring noted on the thighs.

    07:57 Our last option we need to talk about as a stomach pain.

    08:00 You might be already thinking, wow, I bet that stomach pain is related to stress.

    08:05 That's absolutely possibly true.

    08:07 But it doesn't yet really rise to the level of priority, given our other options.

    08:13 So option one should be statements about the family.

    08:17 Yes.

    08:19 And then option two, scarring noted on inner thighs.

    08:23 There's your answer.

    08:24 How'd you do? Okay, let's try a second question based on that same nurses note.

    08:32 In this question, we're going to drag Taylor's subjective data that indicate that she might be at risk for self-harm into the box on the right.

    08:40 We might use some of the options, or we might use all of the options.

    08:45 Let's see what we come up with.

    08:47 Here's the subjective data: Statements about our family, social isolation at school, staying with the school nurse, verbalizing that the stomach pain is actually associated with Taylor's sexual identity, or that Taylor identifies as a lesbian.

    09:01 So which subjective data should be moved over to the risk factor column? We'll go through each one individually.

    09:09 Statements about her family.

    09:11 They were heartbreaking for sure.

    09:13 And her negative opinion about her family and how they feel about her sexual identity really does place her at increased risk for self-harm.

    09:22 If you don't have support, that's a really tough spot.

    09:25 So we're going to move that one for sure.

    09:28 Social isolation at school.

    09:30 This is a 15 year old teenager who feels like she's not supported by her peers.

    09:35 Absolutely this would place her at increased risk for self-harm.

    09:39 Staying at school with the nurse.

    09:41 Well, this is a safe spot for Taylor, absolutely, because she doesn't feel supported by her peers.

    09:47 But, this in and of itself does not place her at increased risk for self-harm.

    09:51 So that one won't move.

    09:53 Verbalizing that our stomach pain is associated with her sexual identity.

    09:57 Well, again, it seems like there's some correlation here.

    10:00 But that in and of itself does not place her at increased risk for self-harm.

    10:04 It's just really a trigger.

    10:06 Identifies as a lesbian.

    10:09 While we've already talked about the fact that teens who identify as LGBTQIA+ may be ostracized by peers, and by their family, and feel like they may not have support, they're absolutely at increased risk for self-harm.

    10:22 So we're going to move that.

    10:24 So here are the three correct answers for this question.

    10:28 It's now two o'clock, and we have the results back from the X ray.

    10:32 And the nurse notes that Taylor and the parents are informed that the abdominal X ray is completely normal.

    10:39 And the healthcare provider really states that since all the physical symptoms are normal, we're going to discharge Taylor, and she should be followed up by a primary care provider.

    10:50 So we know there's some other things that we really want to dig into on this case, and make sure that Taylor receives the best care possible.

    10:57 So this is what this question is intended to figure out.

    11:01 So for each potential nursing intervention, we want you to specify whether the intervention is indicated or not, before Taylor goes home.

    11:10 We have indicated and not indicated.

    11:12 We have to have at least one answer in each column.

    11:15 So keep that in mind.

    11:16 Here are the nursing interventions to consider: Question Taylor again, about the scarring, contact Child Protective Services, ask open ended questions about the family and the peers responses, ask yes or no question about current thoughts about self-harm.

    11:33 Asking open ended questions about Taylor's sexual activity, providing information and education on mental health services for the family and for Taylor, and discuss sexually transmitted diseases.

    11:45 So take a moment, think about whether they are indicated or not indicated interventions.

    11:54 Okay, let's figure out the right answer whether the intervention is indicated or not.

    12:00 Questioning the client about the scarring.

    12:03 Should the nurse ask Taylor about the scarring on her thighs? Absolutely.

    12:07 There may be something else going on here.

    12:08 And we need to know what that is.

    12:11 Contact top Protective Services.

    12:13 Clearly Taylor's parents are not supportive of her sexual identity.

    12:17 But there's nothing in this case that rises to the level of needing to contact Child Protective Services.

    12:22 So that at this point, is not indicated.

    12:25 Asking open ended questions about family and peer responses.

    12:29 That has a lot to do with why Taylor is here.

    12:32 So it might be a good idea to get some more information about that to figure out what the next steps might be.

    12:37 So we'll definitely do that.

    12:40 Ask yes or no questions about thoughts of self-harm and suicide.

    12:44 We already know that Taylor is self-harming.

    12:47 And so we want to follow up, given her history, both physical, and our history of identification as LGBTQIA+.

    12:55 Both of those things place her at risk for further self-harm, which could end up in suicide, we absolutely have to ask this question.

    13:03 And we need to make sure we get an affirmative answer before we let Taylor go home.

    13:07 Ask open ended questions about sexual activity.

    13:11 Yes.

    13:12 Absolutely.

    13:12 There's a lot to unpack here about what Taylor is experiencing.

    13:16 And she might need more information and education.

    13:18 But we're in the emergency department.

    13:20 And Taylor doesn't know the nurse.

    13:22 And so this might not be the best space to ask questions about this.

    13:26 So maybe not here.

    13:28 Definitely follow up.

    13:29 But this is not indicated at this time.

    13:32 Provide education on mental health resources for the client and family.

    13:36 Again, we're nurses, we educate, and we want to make sure that we really give Taylor and her parents all the things that they need in order to really move to the next steps of helping Taylor to feel better.

    13:50 We're going to do this.

    13:51 Education, yes, yes, yes.

    13:53 And the final option, discuss prevention of sexually transmitted diseases.

    13:58 Again, this gets into really deep information.

    14:01 We don't really know that Taylor is sexually active at this point, we just know, as she said that she's into girls.

    14:07 This needs time, it needs a trusting relationship and I don't know if we have that yet.

    14:13 So at this point, important, not indicated.

    14:18 Here are the correct answers.

    14:20 Okay, let's talk about the next nurses note at three o'clock.

    14:24 This is the time when the nurse follows up on the scarring on the thighs and writes a note about it in the chart.

    14:30 So review it while we talk about it.

    14:33 So the nurse discloses that she talks to the parents about the scarring, and the parent starts to cry and she begins to hug Taylor, which is certainly reassuring.

    14:43 And she asks both her daughter Taylor and the nurse, you know, I thought it was just a phase.

    14:49 What can I do? This is a really great sign and we absolutely want to put that in the chart and make sure that that is there.

    14:56 So in response to the nurses note, let's see Think about what kind of teaching points we might want to help the parent to really understand before Taylor goes home.

    15:06 So thinking about positive parenting skills, what are going to be the best answers? What's going to be essential, and what's going to be non essential.

    15:14 Here are the teaching points: Regular non judgmental listening time, that certainly is going to be essential.

    15:21 Taylor really admits to feeling not heard or seen by her family.

    15:25 So that's going to be essential.

    15:29 Medication Therapy.

    15:31 Well, it may be that Taylor may need medication or the family may need medication, but again, this goes beyond the scope of what we're doing in the ED at this time.

    15:39 So that's non essential.

    15:41 Family therapy resources.

    15:43 Definitely sounds like that would be helpful both for Taylor and probably her parents and maybe her siblings.

    15:48 So this is going to be essential.

    15:51 Agreement on a safety plan.

    15:53 Now, we don't know the results of Taylor's answer to the self-harm question in terms of suicide.

    15:58 But we absolutely want to agree on a safety plan either way.

    16:02 Even if she says no, we know that teenagers change their mind often and we want to make sure there's a safety plan in place for her.

    16:09 So this is going to be essential.

    16:11 Required and critical.

    16:14 Resources on mental health education classes, yes, there may be some depression here, social isolation can certainly lead to that.

    16:21 So resources on mental health education, that is going to be essential.

    16:26 We'll check that one.

    16:27 LGBTQIA+ advocacy organizations.

    16:31 Well, again, this is certainly important, we definitely don't want to dig down into an issue that we don't have time to support.

    16:37 So we're going to leave that for the primary care provider to really provide lots of information about.

    16:42 So at this particular juncture, it would be non essential.

    16:46 Important, not essential.

    16:49 All right.

    16:50 We have one more question in this case.

    16:53 So which three assessment findings? So there are three, we've given you a number, indicate that the teaching the nurse gave is successful.

    17:02 Option number one, the client and Mother appear interested in the materials on the mental health therapy and educational resources.

    17:09 Absolutely.

    17:10 They're interested and engaged.

    17:12 This seems like it's helpful.

    17:13 We'll check that.

    17:15 The next option, Taylor states, I promised to tell my family if I want to cut or hurt myself, this goes along with the safety plan.

    17:25 And if Taylor saying this, that absolutely indicates that the plan was successful.

    17:31 The next option, the parent is seeing gently helping Taylor change into her regular clothes.

    17:36 So we're seeing empathy and caring and compassion on the part of the parent, we want to see that.

    17:41 Remember, Taylor was feeling really isolated from her family.

    17:44 This is important.

    17:45 We'll check that one too.

    17:48 The client's parents dates to Taylor, the client's parents states to, Taylor, I'm not sure a class will help me understand why you're upset.

    17:57 That doesn't feel supportive, or empathetic.

    18:00 So this would not be success.

    18:02 We won't check that one.

    18:04 The final option, Taylor says to the nurse, I'm not sure how spending time talking about this situation will help me.

    18:12 Well, that sounds like Taylor doesn't feel like any of the resources would be helpful.

    18:17 And this certainly is not successful.

    18:19 So we won't check that one either.

    18:21 So options one, two, and three are the correct answers.

    18:26 Guess what? You did it.

    18:28 All done.

    18:29 Great job.

    About the Lecture

    The lecture DEIB Case Study: Anticipating Unique Health Risks in Clients Who Identify as LGBTQIA+ (Nursing) by Jacquelyn McMillian-Bohler, PhD, CNM is from the course NGN DEIB Case Studies.

    Author of lecture DEIB Case Study: Anticipating Unique Health Risks in Clients Who Identify as LGBTQIA+ (Nursing)

     Jacquelyn McMillian-Bohler, PhD, CNM

    Jacquelyn McMillian-Bohler, PhD, CNM

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