DEIB Case Study: Impact of Social Determinants of Health on Patient Outcomes (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 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!

    About the Lecture

    The lecture DEIB Case Study: Impact of Social Determinants of Health on Patient Outcomes (Nursing) by Jacquelyn McMillian-Bohler, PhD, CNM is from the course NGN DEIB Case Studies.

    Author of lecture DEIB Case Study: Impact of Social Determinants of Health on Patient Outcomes (Nursing)

     Jacquelyn McMillian-Bohler, PhD, CNM

    Jacquelyn McMillian-Bohler, PhD, CNM

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