00:01
Hi, I'm Jackie,
let's do a case study.
00:05
This one's entitled:
Implications of social
determinants of health
on patient outcomes.
00:10
I'd like to introduce you
to Milo and his grandmother.
00:14
In this case study,
the pediatric intensive
care or PICU nurse
is caring for Milo.
00:19
He's a 10 year old boy
who is admitted for acute
asthma exacerbation,
and his anticipated
date of discharge
is about two days away.
00:28
Milo was recently in the
emergency department.
00:30
So let's review that note
he presented in
respiratory distress.
00:34
He had auditory expiratory
and inspiratory wheezes,
shortness of breath,
he was unable to speak in
more than one or two answers
to any of the questions.
00:43
He was tired and he was very
passive during the exam.
00:47
An intravenous line was started
and he was given
nebulizer treatments.
00:51
His grandmother denied
any nausea and vomiting
or any fever,
but she did report
that Milo symptoms
had been getting worse
over the last 12 hours
and the inhaler, no, it
just wasn't working anymore.
01:05
She also reported that
Milo had similar symptoms
and actually been in the ED
three times in the
last six months.
01:12
So the decision was
made to admit Milo
from the emergency
department into the PICU.
01:18
And the admitting nurse
is reviewing the notes
and the laboratory values.
01:23
So under his medical history,
Milo is significant
for persistent
asthma and frequent URIs.
01:29
Remember, that's upper
respiratory infections.
01:31
And let's take a look at
his labs are written here.
01:34
Take a moment and review
and see what you think
might be abnormal.
01:42
Now we're ready for the
very first question.
01:45
Which data from the clients
history of the present illness
does the nurse determined
to be significant?
So which answers say that
something is definitely going on?
This is a select
all that applies,
so there's going to be
more than one answer.
02:00
The first one:
Eosinophil level.
02:03
Well, it's slightly elevated
and that's indicative
of an allergen
component of a
respiratory condition
and it definitely needs
further investigation.
02:12
So we're going to
check that one.
02:14
Vitamin D level.
02:15
Well Milo's vitamin
D level is low,
and it indicates malnutrition.
02:20
This definitely needs
further investigation.
02:23
We'll check that one.
02:25
White blood cell count.
02:26
Okay.
02:27
Absolutely. I agree.
02:28
It is lightly elevated.
02:30
When you think about it in
comparison to the reference range.
02:33
But there's really no indication
that there's an
infection at this time.
02:36
So we're actually not
going to check that one.
02:40
Frequent URI.
02:41
Well, that's actually
also associated
with vitamin D deficiency,
and he's had three URI
in the last six months.
02:49
Oh, yeah, we're
gonna check that one.
02:51
And finally, passive cooperation
during medical
assessment and care.
02:56
Well, Milo is a little kiddo.
02:57
And that's pretty normal
and he doesn't really
feel that well.
03:01
But it's not something
that we need to determine
a significant at this
particular point.
03:06
So the three answers:
Eosinophil level,
vitamin D level,
and frequent URI.
03:12
Now let's see what happens
when Milo is all settled
into his room in the PICU.
03:17
From the nurses
notes, we learned that
he was reassessed to see if the
ED interventions were effective.
03:23
Milo is now able to follow
directions and he's cooperative.
03:26
He's still experiencing
expiratory wheezes,
but he's now able to
speak in full sentences.
03:32
He was given a video game
that's usually provides
comfort for kiddos
and that's pretty standard.
03:38
But what he says is,
I don't have any games
like this at home.
03:41
Grandma says it costs too much.
03:44
The nurse also notes that
Milo appears underweight.
03:47
This is noted in the
electronic medical record, EMR.
03:51
And that his BMI
is less than 14.
03:54
The grandma says that
they actually share
the meals on wheels deliveries
and that he receives free
breakfast and lunch at school.
04:00
Milo asks for as many
as you can give me
when he's asked if he would
like ginger ale and popsicles.
04:07
When asked if there's
anything in their home
that could be making Milo sick,
the grandma says,
"Well, you know,
he likes school
better than our place.
04:16
We have a lot of roaches
and they're a problem."
They've sprayed but it's
really not getting any better.
04:21
And it's also noted
in the clients history
that the client lives with
his maternal grandmother
in subsidized housing.
04:30
Now I have a question for you.
04:32
Complete the following sentence
by choosing from
the list of options.
04:36
Here's the sentence.
04:37
The nurse is currently most
concerned about the clients _______
and _______
from the client's
admission assessment.
04:45
So what information did we get
from the admission assessment,
the labs, all of those things,
that tells us there
may be a problem.
04:52
We're looking for
most concerned.
04:55
Here are the options.
04:56
Remember we're looking for two.
04:59
The first one.
05:00
Living in subsidy as housing.
05:02
Well, in and of itself,
living in subsidized
housing is not a concern.
05:06
If there's a problem with
the roach infestation,
that may be an issue,
but that's not what's here.
05:12
The only thing it says is
living in subsidized housing.
05:15
So we're not going
to choose that one.
05:17
Roach infestation.
05:19
Well, insect debris and
aerosolized pesticide treatments.
05:24
That has been associated
with asthma problems.
05:27
So that one sounds like something
we should take a look at.
05:29
So how about we check that one.
05:32
Request for ginger
ale and popsicles.
05:35
Well, this is
certainly interesting
and might indicate some
issues with food insecurities,
but that's not what we're most
concerned about at this moment.
05:42
Remember, Milo was admitted
for respiratory issues
and asthma exacerbation.
05:48
So we wouldn't check that one.
05:50
BMI being less than 14.
05:53
Well, that's very
low for a child.
05:55
Definitely inappropriate.
05:57
So this one sounds like
something we need to check on.
05:59
So let's think about this one.
06:01
But let's look at the last one.
06:03
The child's reluctance to
stop playing video games.
06:06
Well, most kids like
playing video games,
and that's not unusual.
06:10
And the fact that he doesn't
want to stop is also not unusual.
06:13
So we won't check that.
06:15
So we think about
correct answers,
roach infestation,
and BMI being less than 14,
absolutely fit the bill.
06:23
So here's the full sentence.
06:25
The nurse is currently
most concerned
about the client's
roach infestation
and BMI being less than 14
from the client's
admission assessment.
06:36
It's now the next day and the
nurse is reviewing a note.
06:40
For the health care provider,
Milo symptoms have improved
and he's going home.
06:44
Discharge medications
are ordered
and instructions are given to
talk to Milo and his grandmother
about an Albuterol inhaler
and maintenance fluticasone,
propionate/salmeterol.
06:55
The grandmother asks if they
can have the Albuterol inhaler
they've been using
in the hospital,
and whether or not she really
has to fill the prescriptions.
07:04
The Albuterol inhaler that
the grandmother has from home
is expired and it's empty,
and they don't have the
money to pay for a new one.
07:12
When the nurse asks that Milo
demonstrate how he
uses the inhaler,
he doesn't take a full breath
and he doesn't wait
in between doses.
07:21
When the nurse asks
the grandmother
which primary care provider the
client records can be set to,
the grandmother
reports that Milo
actually doesn't
have a pediatrician.
07:30
And they prefer to use
the emergency department
because they can
walk there from home
and they don't have a car.
07:36
So can you put everything
together and answer a question.
07:40
Let's give it a try.
07:41
Complete the following sentence
using the drop down
options provided.
07:45
Here's the sentence,
the nurse is most
concerned about ______
as a result of ______.
07:52
So most concern priority,
what is the most
important thing?
So here are our options,
malnutrition,
developmental delays
and asthma exacerbation.
08:03
So malnutrition,
certainly seems like
it might be an issue.
08:08
But is that what we're going to
solve right here on this admission.
08:11
Is it causing any problems that
we need to deal with immediately?
Important,
but maybe not immediately.
08:18
Let's see what are
other options are.
08:20
Developmental delays.
08:22
Well, there hasn't been any report
of poor academic performance
or any developmental
delays by the grandmother,
nothing noted in the chart.
08:29
So this is not going to
be our option for sure.
08:32
But our third option,
So clearly, asthma
exacerbation has
So clearly, asthma exacerbation
has been an ongoing
issue for Milo
and we think about what needs
to be dealt with right now.
08:44
Asthma exacerbation,
trumps malnutrition.
08:47
So the correct answer,
asthma exacerbation.
08:51
Now let's think about what
the contributing factor is.
08:54
What is this the result of?
So our options are:
Insect infestation,
food insecurity,
or the absence of a
biological parent.
09:04
Well, we've already
discussed the relationship
between the roach infestation
and possible exacerbation
of the asthma.
09:10
So that seems like that's
probably a pretty good answer
but again, let's look
at our other options,
food insecurity.
09:17
There may be some issues here.
09:19
We don't know that for sure
but we know that he's sharing
his meals with his grandmother
that are meant for one person
and that he's having lunch
and breakfast at school.
09:28
So there may be
some issues here.
09:29
But is this what's causing
the asthma exacerbation?
Because that's what we've
chosen for our initial response.
09:35
So maybe not this answer.
09:37
Let's look at the last one.
09:39
Absence of a biological parent.
09:41
While absence of a
biological parent
does not have a direct
relationship to asthma.
09:46
He has a loving grandmother
and someone who's
providing care for him.
09:50
So that is absolutely
not the right answer.
09:52
So the best answer for
the contributing factor
is insect infestation.
09:58
So the sentence should be:
The nurse is most concerned
about asthma exacerbation
as a result of
insect infestation.
10:09
Okay,
I've got another
question for you.
10:12
There are a lot of words
on this slide, I know.
10:13
But we're gonna go
over the instructions
and break it down really slow.
10:16
So let's start with that.
10:18
For each client
need listed below,
click to specify the
potential intervention
that is likely to
mitigate or lessen
the impact of the associated
social determinant of health.
10:29
Now, there might be
more than one answer
on your each column,
but there has to
be at least one.
10:34
So hopefully that helps.
10:36
But here we go.
10:37
So our client needs
our nutritional
safety and infection control,
health promotion
and maintenance.
10:44
Let's take a look
at nutritional.
10:46
So the options are referral
to outpatient case management
for assistance with
nutritional resources.
10:53
Well, that certainly sounds like
something that needs to happen,
and that might help mitigate the
issues related to food insecurity.
10:59
So let's check that one.
11:01
Inpatient Nutritional Consultant
to provide teaching and
resource assistance.
11:07
Well, wouldn't it be
great to do some teaching
while Milo and his grandmother
are here in the PICU?
Absolutely.
11:13
So let's check that one.
11:15
Last one.
11:15
Evaluation by child protective
services for malnutrition.
11:20
Hmm.
11:20
This seems to get
into those issues
of assuming that
just because Milo
is living with his grandmother,
that he's not receiving
the care that he needs.
11:27
And that really has not been
proven to be true so far.
11:31
So we are not going
to check that.
11:34
Safety and infection control.
11:37
Here are options:
Accident prevention.
11:40
Well, accident prevention
isn't going to mitigate
anything related to social
determinants of health.
11:46
It is certainly an issue
for children of this age,
certainly a risk factor and
a potential for problem.
11:52
But it's not related to
social determinants of health.
11:54
So we're not going
to select that.
11:57
Principles of
infection prevention.
11:59
Well, this client is
at risk for infection.
12:02
Absolutely, there's some
malnutrition that's likely going on
and this frequent URI,
certainly an issue,
so education should be
provided about this.
12:13
Community danger, awareness.
12:16
I didn't hear anything
about community danger,
or anything like
that, in the story.
12:21
We heard about roaches,
but that's not dangerous.
12:24
So we're not going
to check that.
12:27
Now let's look at
the final column.
12:29
Health promotion
and maintenance.
12:31
Inhaler technique.
12:33
Well, clearly, we need to do
some teaching related to that.
12:36
And that's really going to help
make sure that this
asthma gets better.
12:40
So how about we check
that one for sure.
12:43
Principles of asthma management.
12:46
Well, making sure that
Milo and his grandmother
absolutely understand
how best to manage asthma
so that it gets better.
12:53
That's going to
improve outcomes.
12:55
So we would check that one.
12:57
And finally, education on
public transportation services.
13:01
True.
13:02
You know, the grandmother
mentioned they don't have a car,
but that doesn't
mean that they need
education on public
transportation.
13:09
So without evidence of
any issues with that,
we're not going to check that.
13:14
So here are the correct answers.
13:17
Now we're ready for
the final question.
13:19
Just to set it up.
13:20
The nurse has been chatting
with Milo's grandmother
and providing some education.
13:24
So the instructions are
for each teaching point,
choose the grandmothers response
that indicates that the
teaching has been effective,
we'll have at least one answer,
but likely more than one
answer under each topic.
13:36
So the first topic
is explains the role
and purpose of care management.
13:40
So which statements by the
grandmother indicate that
she understands
what the roles are?
Let's look at the
first statement.
13:48
A care manager can help
me get more benefits
since I haven't now and
I could get better food.
13:53
Is that true?
Absolutely, it is,
we would check that.
13:58
A care manager could
help me get him to
a regular doctor and help
arrange transportation.
14:03
Could a care manager do that?
Yes, they can and
will check that.
14:09
They should be using
roach bait systems
and a care manager could
help me ask for that.
14:14
So the idea of advocating
for what the needs are
and what specific needs Milo has
in order to improve his asthma,
definitely something
that case manager can do.
14:23
So we would check that.
14:25
I should call the care manager
when he gets sick like this again.
14:29
Well, the care manager is
not the health care provider
and if there's an issue,
we want the grandmother to
call the health care provider.
14:35
So that one is incorrect.
14:37
So we won't check that.
14:39
And finally,
a care manager will make
all his appointments
and go with him,
so I don't have to.
14:45
No, the care manager
doesn't do that.
14:48
The grandmother is still
going to need to provide
that oversight and supervision
so that one, not correct.
14:55
The second teaching point is
related to the inhaler technique.
14:59
So which statements by
the grandmother indicate
that she's got it?
Her first statement:
He should breathe out real deep
before breathing
in the medicine.
15:07
Is that how we use an inhaler?
You betcha.
15:10
We're going to check that one.
15:12
He should wait 30 to 60 seconds
between each inhalation.
15:16
Absolutely.
15:17
Milo should do that.
15:18
That is correct technique.
15:20
He should use the new one
when he can't breathe.
15:22
So this is the blue tick zone.
15:24
Should he be using that
one as a rescue inhaler?
No, that's a maintenance dose.
15:30
So we wouldn't check that.
15:32
And the last statement,
the spacer is for when he doesn't
think he's getting enough medicine.
15:37
That implies that the spacers
should just be used as needed.
15:41
And that's definitely
not correct.
15:43
Spacers should be used
with every single dose.
15:47
So we won't check that.
15:49
So here are the correct answers.
15:52
Okay, one last question.
15:54
The nurses reviewing the
notes from the healthcare team
before discharging
the client home.
15:59
So which statements
from the notes
suggest that the healthcare team
has inadequately addressed,
meaning they haven't
done something right.
16:08
And they haven't thought about
the social determinants of health
and their effect on
Milo's situation.
16:13
This is a select all that apply
so likely more than one answer,
we're looking for things that
inadequately address social
determinants of health.
16:22
Here we go.
16:23
Appointment and travel
assistance were arranged
with a pediatrician located close
to the family within two weeks.
16:30
Well, this looks like we've tried
to overcome some of the barriers.
16:33
So this one actually
is doing well.
16:36
So we're not going
to check this one.
16:39
The client did a return
demonstration of breathing out
before inhaling the medication.
16:44
Well, this actually addresses
issues related to
health literacy,
which is a component of a
social determinants of health.
16:51
This is correct.
16:52
So we won't check that.
16:54
Community care manager
to contact the landlord
for bait system placement.
16:59
Well, this is not
empowering the grandmother
to ask for what she needs.
17:03
And so this is an example of
inadequately helping someone.
17:06
So we would check this one.
17:09
Family given a list of internet
resources on asthma management.
17:13
Well, this is
absolutely inadequate,
because we have an
issue of access here.
17:17
So providing just a list
without any thought about
whether the clients can
actually reach that service
or whether it's culturally
appropriate or anything else
is inappropriate and inadequately
addressed with the issue.
17:29
So we would check that one.
17:32
And the last option,
grandmother promises to fill new
prescriptions after discharge.
17:37
Remember, in the
earlier conversation,
grandma was not ready to
fill those prescriptions
because of lack of resources.
17:43
So things have been addressed.
17:45
So this is adequately addressed,
and so we won't check this one.
17:50
So the only thing that is
problematic in this list
is that the family is given
a list of internet resources
on asthma management.
17:58
That is inappropriate,
and it inadequately addresses
the influences of social
determinants of health.
18:05
We're all done.
18:06
You did it.
18:07
Great job!