00:01
Hi, I'm Jacqui.
Let's do a case study.
00:04
I want you to meet Evelyn.
00:06
Evelyn is a client who presents
to the emergency department
accompanied by her adult daughter
after visiting an
urgent care facility
and then being instructed
to go to the ED.
00:17
Evelyn presents with nausea,
fatigue, and shortness of breath.
00:22
The nurse is now assessing
her current vital signs
while gathering her
medical history.
00:29
Take a moment and review the
results of the history and physical.
00:39
Now we're ready for the question.
00:41
Highlight the findings on the table
that should be
significant to the nurse.
00:48
Now let's see which data points
should have been highlighted.
00:51
First sex. And when I say sex.
00:55
I mean sex and not gender identity.
00:57
Evelyn, sex is female.
00:59
And this is significant
because females can present
with slightly different symptoms for
cardiac related events than males.
01:07
The classic symptoms
of a heart attack,
chest pain, arm pain, jaw pain,
those may not be present
in the female client.
01:16
Females may present with more
vague symptoms such as fatigue.
01:20
Hmm. The differences
between males and females
have to be taken into consideration
when considering
this disease process.
01:28
Next, let's look at ethnicity.
Everyone is African American.
01:33
Ethnicity matters in
this particular case,
because of what we understand
about health inequities.
01:39
So syndromes such as
hypertension and diabetes
may be more likely to occur
in this particular population.
01:45
Persons of color also experience
healthcare quality disparities
in the presentation
of coronary syndromes.
01:52
So we have to pay attention
to ethnicity in this case,
because it may affect outcomes.
01:58
Now let's talk about
Evelyn's vital signs.
02:01
These are particularly
related to her presentation.
02:04
Her respiratory rate was 24.
02:07
This is elevated and is
of particular concern
because this indicates that
Evelyn's body is working hard
to obtain adequate oxygenation.
02:16
The heart rate is also elevated.
It's 110 beats per minute.
02:21
And this increase is concerning
because Evelyn's heart is working
hard in order to compensate
for the lack of oxygen.
02:28
her blood pressure is 168/112.
02:32
Ideally, the adult blood pressure
should be around 120/80.
02:37
Hypertension is a consistent
forceful pushing of blood
against the arterial walls
and this can cause
damage of the inner lining.
02:44
We want to make sure we bring
this blood pressure down,
but right now it's elevated
and so therefore
it should be highlighted.
02:51
The other vital signs are normal.
02:55
Evelyn's past medical history --
diabetes, cholesterol, anemia,
and hypertension.
03:01
Evelyn's also taking
several medications,
which is significant
because it lets us know
that her past medical history
conditions are being managed.
03:10
When we look at her history
of substance use,
we find that both that and
her social history are benign.
03:17
So they're not relevant
in this particular case.
03:22
Five minutes later,
Evelyn reports feeling nausea,
fatigue, and shortness of breath.
03:27
She also reports a
sensation in her chest
where her heart feels
like it's racing,
and she has aches and
her shoulders and neck.
03:34
These are the very same symptoms
that occurred yesterday.
03:39
Evelyn was actually seen
yesterday in an urgent care clinic
after her daughter urged her to go.
03:45
She was told she had
indigestion and stress fatigue.
03:50
She was discharged
with instructions
to start a two week
regimen of omeprazole
and over the counter ibuprofen.
03:57
Her daughter reports,
"My mom isreally stubborn
and doesn't want to be seen.
04:02
But she hadn't gotten any better."
Today, they returned to the same
urgent care clinic
due to those same symptoms
not improving,
and then they were
told to come to the ED.
04:13
It's important to note that
in this particular case,
Evelyn has a strong advocate
in her daughter.
04:19
Now imagine
all of our other clients
who might report to the urgent
care facility or to the hospital
without someone there to advocate
and to urge them to be seen.
04:30
Clearly, Evelyn is in
some sort of distress,
and this needs to be addressed.
04:35
So in times when our clients
don't have advocates,
nurses,
you have to be the advocate.
04:41
Now, let's see if we can answer
the next question.
04:45
Indicate if Evelyn
is at risk or not at risk
from the following responses
while she's receiving health
care treatment in this setting.
04:54
Here are the potential responses.
04:57
Take a moment and identify
whether you think
she's at risk are not at risk.
05:08
Now, let's go through the answers.
05:10
We're going to look at the
first two responses together
because they're related.
05:15
Minimization of symptoms
related to gender,
or related to being
a person of color.
05:21
As we've already discussed,
research shows
that persons who identify
as female or persons of color
are more likely to experience
a minimization of symptoms
in the healthcare system.
05:32
Definitely, Evelyn is a
person of color, and female.
05:36
So she's at risk for both of these.
05:39
Denials of medical treatment due
to not having health insurance.
05:43
Under the 1986, Emergency Medical
Treatment & Labor Act
You may hear this
referred to as EMTALA,
denying a medical screening
examination when it's requested
or when there is an
emergency is illegal.
05:59
So that is not something
that Evelyn is at risk for,
in this particular case.
06:04
Inappropriate discharge to home.
06:06
Well, we've already seen Evelyn
be inappropriately discharged.
06:11
So unfortunately, even though she's
now in the emergency department,
this is still a risk.
06:16
And finally,
excessive medical treatment
due to the vagueness of complaints.
06:21
Well, actually, Evelyn is at risk
for not receiving adequate
medical treatment, not excessive.
06:28
So here's a summary
of the correct answers.
06:33
It's now been 15 minutes after
Evelyn arrived in the ED.
06:37
The healthcare provider
has now written orders.
06:40
Take a moment and review
what's been prescribed.
06:48
Now we're ready for
the next question.
06:50
We're going to drag the options to
complete the following sentence.
06:55
The nurse determines the client
is most at risk for blank
due to blank in the female
African American population.
07:04
Take a look at the options
under option one and two,
and see if you can
fill in the blanks.
07:15
Now let's look at the
answers under each option.
07:18
Under option one, misdiagnosis.
07:21
Evelyn is certainly at
risk for misdiagnosis.
07:25
We know that the differences
in clinical presentation
for acute coronary syndrome is very
different between males and females.
07:33
We also know that because
Evelyn is African American,
her risk for experiencing
health inequities
is definitely present.
07:41
So misdiagnosis might be an answer.
But let's see what else.
07:45
A decrease in quality of care. Hmm.
07:49
Some of this we answered
under misdiagnosis.
07:52
So a decrease in quality of care
sounds like more
of an umbrella term,
which might cover all the ways that
African Americans may experience
differences in how they
achieve health care.
08:03
The next option,
leaving against medical advice.
08:07
Well, Evelyn really has it left.
08:10
She was discharged from
the urgent care facility.
08:12
She showed back up
again the next day,
and now she's in the ED.
08:16
This doesn't seem appropriate
in this particular situation.
08:19
So that's not the answer.
08:21
And nonadherence
to the treatment plan.
08:25
First of all, nonadherence
to the treatment plan is
usually never a good option.
08:30
Nonadherence supplies that
people don't have control or
choices about their medical care.
08:35
But it certainly hasn't
happened in this case.
08:37
Evelyn has followed
every prescription
and every instruction
she has been given.
08:42
So that doesn't work in this case.
08:44
So under option one,
the best answer is
a decrease in quality of care.
08:51
Now let's look for
the reasons why Evelyn
might be at increased risk for
a decrease in the quality of care.
08:58
We've already discussed the
increased risk for health inequities
that are experienced by
African American persons.
09:06
So this seems like a great answer.
09:08
But there might be something else.
So let's take a look.
09:11
Poor communication.
09:13
So far,
we haven't had any indication
that there's been poor communication
between Evelyn,
her daughter,
and the hospital staff.
09:21
So that doesn't seem to fit.
09:23
Next social stigma.
09:26
Social stigma tends to cause a
delay in seeking of health care.
09:30
Well, Evelyn went to
the urgent care twice,
and now she's in the ED
so this doesn't seem to fit.
09:37
And finally, lifestyle choices.
09:40
Certainly, this is relevant
in any case
when we're talking about
coronary artery disease.
09:44
However, Evelyn's history,
her social history,
and her substance use history
do not indicate any problems.
09:51
So this would not be
the correct answer.
09:54
So, the correct answer for
option two is health disparities.
09:59
The nurse determines that
Evelyn is most at risk
for a decrease in quality of care
due to health disparities
in the female and African
American population.
10:08
Now we're ready for
the next question.
10:11
Complete the following sentence by
choosing from the list of options.
10:15
The nurse plans on overcoming
the identified barriers
in providing care to the client
by discussing, what?
So what does the
nurse need to discuss?
Look at the options below
and see what you think.
10:35
Now, let's discuss.
10:37
The first option.
10:38
Treatments received
at the urgent care facility.
10:42
While it might be
important to discuss
that Evelyn visited
the urgent care facility,
if we think about the diagnosis
of indigestion and stress,
we know that we have
to move beyond this.
10:53
So read discussing what
happened at Urgent Care
might actually elicit
bias and not be helpful.
11:00
Current concerns with
the health care provider.
11:03
This seems like an
appropriate option.
11:05
As we're discussing what's
currently going on with Evelyn.
11:08
What she is saying,
what she is doing
in an effort to figure out
what is going on.
11:13
Let's see what else we have.
11:16
Modifiable risk factors
with the client.
11:19
Well, modifiable risk
factors are important,
but this is talking
about diet and smoking.
11:25
And we've already discussed that
this is not particularly relevant
in this case.
11:29
And finally, the importance
of monitoring the client
during the handoff.
11:34
Well, it seems like we've been doing
a lot of monitoring for Evelyn.
11:37
Now it's time for intervention.
11:40
So this is probably not
the best option either.
11:43
Therefore, the answer is,
the nurse plans on overcoming
the identified barriers
in providing care to the client
by discussing current concerns
with the health care provider.
11:56
It's now 35 minutes
after Evelyn arrived in the ED.
12:00
Ondansetron and Metoprolol
were administered at 17:00.
12:04
Remember, that's about
five minutes after she arrived.
12:06
Her vital signs have improved,
and she states,
"I don't feel my heart
racing so much anymore."
She also denies the nausea
and states that the aches and pains
are much better.
12:18
Evelyn is assisted to the bathroom
and upon returning to the bed
the nurse notes
diaphoresis on her face.
12:25
Take a look at these vital signs.
What do you notice is different?
Now we're ready for the question.
12:36
What three actions by the nurse
are examples of providing advocacy
for equitable care while
communicating the client status
with the health care provider?
So take a pause, and see which
three actions you would choose.
12:56
Now let's review the answers.
12:58
We're going to pay particular
attention for looking for responses
that exemplify advocacy and
providing equitable care.
13:07
We want to move
Evelyn's treatment plan forward
and not just listen to her chief
complaints over and over again.
13:14
The nurse says, "I am concerned the
symptoms could be cardiac related."
This displays advocacy for equitable
health care by voicing the concerns.
13:24
Now, Evelyn has
a new symptom of diaphoresis,
which further indicates
cardiac destabilization.
13:32
Suggesting the need
for further testing
by encouraging the provider
to order cardiac troponins
and an electrocardiogram
would also be advocacy.
13:41
Because this means
that the nurse believes
that Evelyn is experiencing
a coronary event
and needs further testing.
13:50
Contributing the client's
worsening symptoms to anxiety.
13:53
Hmm, this is not
advocating for this client.
13:57
The nurse must take
Evelyn's symptoms seriously
and be able to recognize that
she could be presenting with ACS.
14:05
The nurse says, "She has already
been treated for these symptoms."
So shall we check her blood sugar?
Dismissing the current symptoms
is not advocating for the client.
14:15
Remember, diaphoresis also
goes along with cardiac events.
14:20
Because this client is already been
diagnosed with Type 2 diabetes,
The blood glucose would have
likely already been done.
14:27
And finally,
she had a new onset of diaphoresis.
14:30
This symptom is worrisome.
14:32
The nurse is recognizing
that this is further
exemplification of a coronary event
and is reporting exactly
the correct thing.
14:40
So in summary, options one,
two, and five are correct.
14:47
It's now 17:45. Evelyn has been
in the ED for about 50 minutes.
14:52
The nurse discusses
the client's plan of care
with the health care provider
and additional orders are placed.
14:58
Take a moment and
review the new orders.
15:07
So we're ready
for the final question.
15:09
which information provided
by the nurses notes
and the providers orders
support that Evelyn
is receiving equitable care?
Please note that you have to have
at least one item.
15:22
Okay, let's review the answers.
15:25
Remember, we're looking for answers
that move the action forward,
either to diagnosis or treatment
that would be equitable care
in this particular situation.
15:36
So the answers would look
like options one and two.
15:41
Laboratory orders, CBC, CMP,
Troponins, ECG and echocardiogram.
15:49
These are correct.
15:51
An IV with normal saline
initiating an NPO diet.
15:57
These are often
standard treatments in the ED.
15:59
So this implies more of that
watching and waiting and not acting.
16:04
So the correct answers
are the first two. Great job.