Introduction to Health Assessment for the Nursing Professional - Part I PDF

Introduction to Health Assessment for the Nursing Professional - Part I Introduction to Health Assessment for the Nursing Professional - Part I DECEMBER 2021 Introduction to Health Assessment for the Nursing Professional - Part I Copyright © by December 2021 is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted. Introduction This resource is part of a series. Part II of the first Introduction to Health Assessment for the Nursing Professional can be found at: https://pressbooks.library.torontomu.ca/assessmentnursing2/ This book is best viewed via the online, Pressbooks format so that you can view the videos and interactive activities. However, a PDF format is made available. “Introduction to Health Assessment for the Nursing Professional” is an open educational resource (OER) created for undergraduate nursing students at the introductory level. Educators co-curated this OER in collaboration with students for students. This resource is a unique contribution to nursing education as content is theoretically informed by health promotion in the Canadian context and by an inclusive approach to health assessment that incorporates culturally-responsive techniques related to race/ethnicity, gender/ sex/sexual orientation, body sizes/types, and ability/disability. It is the first health assessment resource that is informed by clinical judgment with the goal to facilitate students’ clinical decision making and ability to prioritize care by recognizing and acting on cues and signs of clinical deterioration. Interactive clinical judgment activities and formative assessments to evaluate a student’s learning are integrated throughout the resource. The integration of clinical judgment throughout this resource will support students’ capacity to enhance patient safety and equitable health outcomes as well as their success in writing national nursing exams to become licensed to work as a Nurse. The resource includes five chapters. The first chapter focuses on an introduction to health assessment. In this chapter, students are introduced to health assessment in the context of the related legislation, clinical judgment, priorities of care, guiding approaches, and integrative approaches to health promotion. The second Introduction | 1 chapter focuses on an inclusive approach to health assessment. This chapter is rooted in social justice and provides students with important insight into conducting health assessments from an antioppressive and humanistic lens. The final three chapters are focused on the respiratory, cardiovascular, and gastrointestinal systems. These chapters introduce students to subjective and objective assessments of each system with images and videos demonstrating health assessment techniques. This OER builds on existing open resources specific to health assessment including: Introduction to communication in nursing: https://pressbooks.library.ryerson.ca/communicationnursing/ Documentation in nursing: 1st Canadian edition: https://pressbooks.library.ryerson.ca/documentation/ The complete subjective health assessment: https://ecampusontario.pressbooks.pub/healthassessment/ Physical examination techniques: A nurse’s guide: https://pressbooks.library.ryerson.ca/ippa/ Vital sign measurement across the lifespan: https://pressbooks.library.ryerson.ca/vitalsign2nd/ All of the listed OER are published under an open license. Thus, you can use them for free or modify them to suit your student and course needs with appropriate attribution. In the future, we will be adding additional chapters to the “Introduction to Health Assessment for the Nursing Professional” OER. Licensing This resource is licensed under Creative Commons Attribution NonCommerical. 2 | Introduction to Health Assessment for the Nursing Professional - Part I Funding This project is made possible with funding by the Government of Ontario and through eCampusOntario’s support of the Virtual Learning Strategy. To learn more about the Virtual Learning Strategy visit: https://vls.ecampusontario.ca Accessibility This book was designed with accessibility in mind so that it can be accessed by the widest possible audience, including those who use assistive technologies. The web version of this book has been designed to meet the Web Content Accessibility Guidelines 2.0, level AA. While we aim to ensure that this book is as accessible as possible, we may not always get it right. There may be some supplementary third-party materials, or content not created by the authors of this book, which are not fully accessible. If you are having problems accessing any content within the book, please contact: Dr. Jennifer Lapum at [email protected] Please let us know which page you are having difficulty with and include which browser, operating system, and assistive technology you are using. Introduction | 3 Contact Information and Acknowledgments Contact Information Dr. Jennifer Lapum, PhD, RN, Professor, Associate Director of Quality Assurance, Daphne Cockwell School of Nursing, Toronto Metropolitan University (formerly Ryerson University), Toronto, ON., Canada, [email protected], @7024thpatient Michelle Hughes, MEd, BScN, RN, Professor, School of Community and Health Studies, Centennial College, Toronto, Ontario, Canada, [email protected], @hughes0311 Acknowledgments Instructional design consultant: Nada Savicevic, MA Interactive Design, MArch, BSc (Eng), Instructional Designer, Office of eLearning, Toronto Metropolitan University, Toronto, Canada Biology consultant: Charlotte Youngson, PhD, Department of Chemistry and Biology, Toronto Metropolitan University, Toronto, Canada Copyeditor, Linn Clark Research and Editing Services, Toronto Canada Pressbooks consultant: Sally Wilson, Web Services Librarian, Toronto Metropolitan University, Toronto, Canada Accessibility consultant: Adam Chaboryk, IT Accessbility Specialist, Toronto Metropolitan University, Toronto, Canada Copyright consultant: Ann Ludbrook, Copyright and Scholarly 4 | Introduction to Health Assessment for the Nursing Professional - Part I Engagement, Librarian, Toronto Metropolitan University, Toronto, Canada Thank you to Centennial College Health Studies Lab Team for supporting this project and sharing their lab space to film the assessment videos. Artist / Illustrators Arina Bogdan, BScN, RN (chapter 3-5 images, and cover art) Pelageya Grebneva, Ryerson, Centennial, George Brown Collaborative Nursing Degree Program, Toronto, Ontario, Canada (chapter 3-5 images) Levar Bailey (chapter 2 figure) Student Advisory Committee Christina Amirkhanian, Toronto Metropolitan, Centennial, George Brown Collaborative Nursing Degree Program, Toronto, Ontario, Canada Samin Barakati, Toronto Metropolitan, Centennial, George Brown Collaborative Nursing Degree Program, Toronto, Ontario, Canada Caitlyn Healey, Toronto Metropolitan, Centennial, George Brown Collaborative Nursing Degree Program, Toronto, Ontario, Canada Mehak Khawaja, Toronto Metropolitan, Centennial, George Brown Collaborative Nursing Degree Program, Toronto, Ontario, Canada Tommy Lin, Toronto Metropolitan, Centennial, George Brown Collaborative Nursing Degree Program, Toronto, Ontario, Canada Maruel Isaac Sanchez, Toronto Metropolitan, Centennial, George Brown Collaborative Nursing Degree Program, Toronto, Ontario, Canada Contact Information and Acknowledgments | 5 Conner Sorley, Toronto Metropolitan, Centennial, George Brown Collaborative Nursing Degree Program, Toronto, Ontario, Canada Lauren Sweeney, Toronto Metropolitan, Centennial, George Brown Collaborative Nursing Degree Program, Toronto, Ontario, Canada Gabriel Umrao, Toronto Metropolitan, Centennial, George Brown Collaborative Nursing Degree Program, Toronto, Ontario, Canada Steven Zagada, Toronto Metropolitan, Centennial, George Brown Collaborative Nursing Degree Program, Toronto, Ontario, Canada 6 | Introduction to Health Assessment for the Nursing Professional - Part I CHAPTER 1 INTRODUCTION TO HEALTH ASSESSMENT By Dr. Jennifer Lapum, Michelle Hughes, Dr. Oona St-Amant, Dr. Lisa Seto Nielsen, Mahidhar Pemasani, and Riddore Creer Chapter 1 - Introduction to Health Assessment | 7 8 | Introduction to Health Assessment for the Nursing Professional - Part I Learning Outcomes Understand the role of health assessment. Apply the cognitive steps of clinical judgment. Understand approaches to health assessment. Recognize the role health promotion plays in health assessment. Learning Outcomes | 9 Introduction to Health Assessment Health assessment is the first phase of the nursing process and involves the collection and analysis of client data. Although it is the first phase, it is an ongoing process. Data collected as part of the health assessment process can be categorized as subjective and objective data. See Table 1.1 for an overview and examples of subjective and objective data. Table 1.1: Overview and examples of subjective and objective data – adapted from Lapum et al., https://ecampusontario.pressbooks.pub/healthassessment/ 10 | Introduction to Health Assessment for the Nursing Professional - Part I Data Subjective Information that a client or another person (i.e., family, caregiver) shares with the nurse spontaneously or in response to questions. Objective Information that the nurse observes when conducting a physical examination, and collecting lab and diagnostic results. Example A client says, “I have had a rash on my ankle and leg for the last two weeks.” A parent says, “My eight-month-old son is having trouble breathing.” A client’s reason for seeking care is “diarrhea for 10 days.” A client types, “I feel sick to my stomach.” The nurse observes that a client has a bright red rash on the dorsal side of the foot, the lateral malleolus, and anterior and lateral side of the lower leg. The nurse observes the client sitting upright, leaning forward, breathing fast with eyes wide open. The nurse measures the client’s blood pressure and records it as 112/84 mm Hg and pulse of 84 beats per minute. Lab test results: potassium (K+) 4.0 mmol/L, fasting glucose 4.8 mmol/L. Chest X-ray report: lungs well inflated and clear. No evidence of pneumonia or pulmonary edema. Subjective data can include information about both symptoms and signs. Symptoms are something that the client feels (e.g., nausea, pain, fatigue). The nurse will not know about a symptom unless the client shares this information. Signs are observable, such as a rash, bruising, or skin perspiration. Signs can be categorized as subjective or objective because the client may tell you about their rash, and you as the nurse may also observe the rash. As reflected Introduction to Health Assessment | 11 in Figure 1.1, a symptom is noted in the image on the left as “I’m having pain” while a sign can be observed in the image on the right, which is the bruising on the left arm. Figure 1.1: Symptoms and signs (Attribution: Taken from https://ecampusontario.pressbooks.pub/ healthassessment/) Age ranges are important to consider when determining normal and abnormal findings during health assessment. Depending on the source, these ranges can vary. Unless specified, we use the following terms and estimates in this resource: Newborns and neonates: newborns are birth to a few hours old and neonate is up to 28 days. Young children: clients who are 5 years and younger, including infants (28 days to 1 year), toddlers (1–2 years), and preschoolers (3–5 years). Older children and adolescents: clients who are 6–17 years, including older children/school-age children (6–12 years) and adolescents (13–17 years). 12 | Introduction to Health Assessment for the Nursing Professional - Part I Adults and older adults: clients who are 18 years and older, including adults (18 years and older) and older adults (65 years and older). Introduction to Health Assessment | 13 Health Assessment: Related Legislation Any health assessment you perform must fall within your nursing scope of practice and be informed by the appropriate nursing College or association practice standards. In Ontario, the College of Nurses of Ontario (CNO) is the legal governing body for nurses, so as a nurse, you must perform health assessment within the CNO legislated scope of practice, the practice standards, and also based on your individual level of competence (i.e., knowledge and expert practice to perform an action). It is important to be aware of controlled acts, which are activities that are considered harmful if performed by someone who is unqualified as per the Regulated Health Professions Act (RHPA) (CNO, 2020a). As per the RHPA, a controlled act must only be performed with an order or when permitted by specific regulations and you must be competent to perform the skill/ procedure (CNO, 2020a). For example, it is within your scope of practice to perform health assessments that move “below the dermis or mucous membrane” or involve putting your finger/hands or an instrument beyond “the external ear canal,” regions where the nasal passages narrow, the larynx, urethra, labia majora, anal verge, or “into an artificial opening in the body” as long as there is an order from a physician AND you are competent to perform this skill/procedure (CNO, 2020a). 14 | Introduction to Health Assessment for the Nursing Professional - Part I Clinical Tip As a nursing student, you are not yet a registered nurse. Therefore, with guidance from your supervisor/preceptor/ clinical instructor, you must assess your competence to perform the controlled act and do so safely. If the decision is that you do not have the knowledge and skill to perform the controlled act, you may observe and use this as a learning opportunity. Keep in mind that many controlled acts are related to interventions (e.g., treatment procedures) that you perform as a nurse, and some controlled acts relate to assessment techniques (e.g., performing an invasive technique). When you perform an assessment, it is important to inform the client what you are assessing and typically share some of the findings that are within your scope of practice (e.g., I noticed inflammation around your ear drum). However, you are not permitted to communicate a diagnosis about what is causing the inflammation around the ear drum. Communicating a diagnosis is not permitted because this is considered a controlled act and outside of the registered nursing specific controlled acts (CNO, 2020b). Communicating a diagnosis is done by certain regulated health professionals such as a physician or nurse practitioner. However, you may be expected to communicate a diagnosis if you are delegated to do so by a physician or nurse practitioner and you have the knowledge to do so. Health Assessment: Related Legislation | 15 In performing any health assessment, you are also required to adhere to the CNO practice standards. Common practice standards that apply to health assessment include information related to consent and permission to touch, privacy and confidentiality, therapeutic nurse-client relationship, and documentation. Many of these CNO documents are based on health laws. It is important to recall that nurses are legally obligated to document their health assessment findings as per the CNO Documentation practice standard, as shown in Documentation in Nursing: 1st Canadian edition. References College of Nurses of Ontario (2020a). Legislation and regulation: An introduction to the Nursing Act, 1991. https://www.cno.org/ globalassets/docs/prac/41064_fsnursingact.pdf College of Nurses of Ontario (2020b). Legislation and regulation RHPA: Scope of practice, controlled acts model. https://www.cno.org/globalassets/docs/policy/ 41052_rhpascope.pdf 16 | Introduction to Health Assessment for the Nursing Professional - Part I Clinical Judgment and Nursing When collecting subjective and objective data, you need to consider clinical judgment. In nursing, the purpose of health assessment is to facilitate clinical judgment, which is defined as: A determination about a client’s health and illness status. Their health concerns and needs. The capacity to engage in their own care. AND The decision to intervene/act or not – and if action is required, what action (Tanner, 2006). The nursing process is the foundation of clinical judgment. However, clinical judgment is more comprehensive, actionoriented, and guided by the philosophy of client safety. Thus, it is important to learn when to act to prevent clinical deterioration, a worsening clinical state related to physiological decompensation (Padilla & Mayo, 2017). To facilitate clinical judgment, you must determine if the collected data represent normal findings or abnormal findings. When findings are abnormal, you must act on these cues as they signal a potential concern and require action. Failing to recognize abnormal findings and act on these cues can lead to negative consequences including sub-optimal health and wellness – and more importantly, clinical deterioration. Some abnormal findings are considered critical findingsthat place the client at further risk if the nurse does not act immediately. The process leading to clinical judgment is described as clinical reasoning. This process involves: Thoughtfully considering all client data as a whole, whether Clinical Judgment and Nursing | 17 each piece of information is relevant or irrelevant, and how each piece of information is related or not related. Recognizing and analyzing cues. Is the information collected a normal, abnormal, or critical finding? Can the information be clustered to inform your clinical judgment? Interpreting problems. What is the priority problem and what are the factors causing it? What else do you need to assess to validate or invalidate your interpretation? What other information do you need to collect to make an accurate clinical judgment? Determining, implementing, and then evaluating appropriate actions (Dickison et al., 2019; Tanner, 2006). The clinical reasoning process is encompassed by critical thinking. This means that when engaging in the process of clinical reasoning, you should systematically analyze your own thinking so that the outcomes are clear, rational, creative, and objective with limited risk of judgment and error. Clinical Judgement A client tells you “I have a headache.” As the nurse, you immediately recognize the cue: headache. However, you do not have sufficient information to analyze this cue and identify the significance. Thus, you may ask a series of subjective questions such as “When did the headache start? What were you doing when it started? Have you ever had this type of headache before?” The client’s response will 18 | Introduction to Health Assessment for the Nursing Professional - Part I provide you detailed information to facilitate your critical thinking and the process of hypothesizing what is going on, and thereby helping you determine what actions to take. Clinical judgement is facilitated by cognitive steps that help you determine when and how to act to prevent clinical deterioration; see Table 1.2. Like the nursing process, these steps should be performed in an iterative manner as per the client situation and your clinical reasoning process. Table 1.2: Clinical judgment steps (developed based on NCSBN, 2020) Clinical Judgment and Nursing | 19 Steps Considerations Recognize cues Recognizing cues involves identifying findings that require action because they are abnormal. This involves what Tanner (2006) calls “noticing” (i.e., recognizing when something is abnormal). You should be asking yourself what matters most? Analyze cues Analyzing cues involves interpreting/making sense of the collected data, what it means, and how it may relate to possible pathophysiological processes. This involves what Tanner (2006) calls “interpreting”, making sense of the collected data. Prioritize hypotheses Prioritizing hypotheses involves figuring out where to start and how to prioritize care. This step involves what Tanner (2006) refers to as “responding” to the collected data Generate solutions Generating solutions involves identifying the various options (e.g., actions/interventions) to address the problem or the abnormal findings/cues. This may involve identifying which solutions are indicated/effective, nonessential, unrelated, and contraindicated. Take actions Taking actions involves identifying the action that should be taken. Examples of actions are specific but could be related to notifying the physician or nurse practitioner, calling for help, monitoring the client, collecting further data. Evaluate outcomes Evaluating outcomes involves determining if the action taken was effective. It may include identifying outcomes that are considered improved, unchanged, or worsened. Activity: Check Your Understanding 20 | Introduction to Health Assessment for the Nursing Professional - Part I An interactive H5P element has been excluded from this version of the text. You can view it online here: https://pressbooks.library.torontomu.ca/ assessmentnursing/?p=131#h5p-6 References Dickison, P., Haerling, K., & Lasater, K. (2019). Integrating the National Council of State Boards of Nursing Clinical Judgment Model into nursing educational frameworks. Journal of Nursing Education, 58(2), 72-78. https://doi.org/10.3928/ 01484834-20190122-03 NCSBN (2020, Spring). Next Generation NCLEX news. https://www.ncsbn.org/NGN_Spring20_Eng_02.pdf Padilla, R., & Mayo, A. (2017). Clinical deterioration: A concept analysis. Journal of Clinical Nursing, 27, 1360-1368. https://doi.org/ 10.1111/jocn.14238 Tanner, C. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211. https://doi.org/10.3928/01484834-20060601-04 Clinical Judgment and Nursing | 21 Priorities of Care Why is clinical judgment important? How does it guide the provision of care? Clinical judgment is important to ensure the nurse’s actions are based on the client’s most important needs. Clients often have several needs, and some are more important than others. As such, nurses need to assess and evaluate the priorities of care: what actions are most important to take first, and then what actions can follow. Typically, priority actions are those that prevent clinical deterioration and death. Maslow’s Hierarchy of Needs Priorities of care can be determined using several frameworks such as Maslow’s Hierarchy of Needs. For example, at the most basic level, life requires an open airway to breathe, the physiological process of breathing, and the circulation of blood and oxygen throughout the body. Airway, breathing, and circulation are the ABCs, which you might have learned if you have taken a cardiopulmonary resuscitation (CPR) course. Maslow’s Hierarchy of Needs was developed to consider basic human needs and motivations of healthy individuals (Bouzenita & Wood Boulanouar, 2016; Francis & Kritsonsis, 2006; Gambrel & Cianci, 2003). Although not well known, Maslow’s work was closely influenced by the Blackfoot tribe in Canada (James & Lunday, 2014). One version includes five levels of needs: those related to physiological, safety, love, esteem, and self-actualization (Maslow, 1943), which can help prioritize care in nursing. Figure 1.2 presents one adapted version of Maslow’s Hierarchy. 22 | Introduction to Health Assessment for the Nursing Professional - Part I Figure 1.2: Maslow’s Hierarchy of Needs (see attribution statement at bottom of page) Drawing upon this framework, a nurse can use health assessments to explore five levels of needs: Physiological needs – fundamental physical needs required for survival such as air, food/drink, sleep, warmth/clothing/ shelter. ◦ Are these basic physiological needs being met? Is the Priorities of Care | 23 client’s breathing and circulation supported? Safety – needs related to a secure physical and emotional environment. ◦ Does the client feel safe and secure in general in life? Does the client feel safe and secure in the healthcare environment? Is the bed lowered to the lowest position when you finish your assessment? Is the call bell in reach? Love and belongingness – needs related to relationships including friendship and family, intimacy and affection, work, and trust and acceptance. ◦ Does the client feel love and belongingness in general in their relationships? More specifically, does the client feel cared for by nurses and other healthcare providers? Esteem – feelings related to self-worth, dignity, respect, and achievement. ◦ Does the client feel respected and valued in general by others? Does the client feel respected and valued within the healthcare environment? Self-actualization – a process or action of reaching one’s full potential and self-fulfillment. ◦ What is important to the client in terms of what they want to achieve in life in general? What are the client’s goals that they may have for themselves in their own health and healing journey? Does the client feel satisfied, confident, and accomplished? You can use Maslow’s Hierarchy of Needs as a guide, but it is important to be aware of the critiques and possible limitations in its application. See Video 1.1 of a conversation between Dr. Lisa Seto Nielsen and Mahidhar Pemasani. 24 | Introduction to Health Assessment for the Nursing Professional - Part I One or more interactive elements has been excluded from this version of the text. You can view them online here: https://pressbooks.library.torontomu.ca/ assessmentnursing/?p=133#oembed-1 Video 1.1: A discussion about Maslow’s Hierarchy of Needs Criticisms of Maslow’s hierarchy are related to it being ethnocentric, based on individualistic societies, and not necessarily taking into account diversity in culture, gender, and age (Bouzenita & Wood Boulanouar, 2016; Francis & Kritsonsis, 2006; Gambrel & Cianci, 2003). It should not be arbitrarily applied to all healthcare encounters. Although you may initially focus on physiological needs to ensure the client is stable, the client may have different priorities that are more important to them. By drawing upon Indigenous knowledge, it is vital to recognize the role of community and advocacy in reaching self actualization at every level (Bennett & Shangreaux, 2005). This is particularly important in the context of systemic racism and oppression and the existing disparities among racialized populations including Black communities and Indigenous People. Levels of Priority of Care Because of the importance of recognizing clinical deterioration in a client, a nurse must always be attuned to the set of physiological needs that are important to maintain life and prevent death. These priorities of care are related to the ABCs – airway, breathing, and circulation – introduced above. These priorities of care are often Priorities of Care | 25 categorized as first, second, or third level, with the first level taking a priority (see Table 1.3). Table 1.3: Priorities of care Priority of care Examples First-level priority of care are problems/issues that reflect critical findings, clinical deterioration and/or are lifethreatening – and therefore require urgent action. Urgent means that action must be taken immediately. A client in respiratory distress as evident by tachypnea, nasal flaring, laboured breathing, intercostal retractions, and decreasing oxygen levels or a client with hemodynamic instability such as chest pain or the absence of or decreasing pulse or blood pressure. Second-level priority of care are problems/issues that may lead to clinical deterioration and may become life-threatening without intervention – and therefore require prompt action. Prompt means that action must be taken quickly. A client with signs and symptoms such as: altered level of orientation, decreased level of consciousness/ confusion, elevated temperature, increasing pain levels, and cold extremities. This may include a client with a head injury who can deteriorate quickly in some cases. You should assess if they experienced a loss of consciousness and have any associated symptoms with a concussion. Third-level priority of care are problems and issues that are typically focused on functional health, client education, and counselling. These should be addressed, but they are non-urgent and can wait until the client is stable. The problem/issue is not acute in nature, but intervention is required to support the client’s activities of daily living, their knowledge level, and their mental health and wellbeing A client who is post-operative and requires assistance with hygiene and mobility, a client who reports increasing stress levels and problems sleeping, or a client who is newly diagnosed with diabetes and requires education around nutrition and monitoring their blood glucose levels. With regard to levels of care, it is essential to consider what is most important to the client. You should treat the client as the expert in their own life – and also as the expert in decisions about 26 | Introduction to Health Assessment for the Nursing Professional - Part I their own healthcare, if they choose. Although a client may have plummeting blood pressure, you need to consider tailoring the intervening action to their wishes. Some clients may not wish for intervention in a life-threatening circumstance. Therefore, you always need to be open to the client’s wishes, but also consider whether they are able to weigh the consequences of their decision (i.e., are they competent to consent?). Urgent Priorities of Care: Mental Health In practice, mental health is typically not categorized as a first- or second-level priority of care unless the client is showing signs of clinical deterioration based on the examples noted in Table 1.3. In some situations, mental health may be positioned as a third-level priority of care, for example when a client is experiencing anxiety, depression, grief, but shows no signs of suicidal ideation. These symptoms should be addressed, but according to this framework, they are considered less urgent compared to first- and second-level priorities of care. However, sometimes, you should think differently about how mental health is a priority of care. In some situations, mental health may take precedence. For example, a client who has attempted suicide or has just overdosed will probably have other physical symptoms as a result and therefore require urgent intervention and constant observation as per Table 1.3. However, the Priorities of Care | 27 descriptions of the priorities of care presented in the table do not account for a client who has voiced a specific plan for suicide and has identified when and how. This client is at very high risk and requires urgent intervention regardless of what may be viewed as their physical health state or history. The description of priorities of care listed above does not account for this except as a third-level priority – but a client with suicide ideation or has voiced wanting to hurt others requires urgent action to protect their own wellbeing and others and the possibility of clinical deterioration as a result of their actions. Intervention Types As illustrated by the text box above, you will need to use your own judgement to determine how to act when a cue presents itself and how to categorize these interventions. This could involve four general types of interventions that you need to be aware of (see Table 1.4) including effective, ineffective, unrelated, and contraindicated. These types of interventions will become more clear as you begin to learn about normal, abnormal, and critical findings for various body systems, and how interventions and actions will affect these findings and the client. Table 1.4: Types of interventions 28 | Introduction to Health Assessment for the Nursing Professional - Part I Provide mouth-to-mouth resuscitation; without compressions, the oxygen will not circulate. Notify the client’s employer. Ineffective interventions are actions that are not adequate to produce the intended result and therefore will not help the client. Unrelated (or non-essential) interventions are actions that will not produce an effect (positive or negative) and therefore will not help the client. Contraindicated interventions are actions that are not A contraindicated intervention is to delay resuscitation until a recommended because they have the potential to cause harm to physician is present. the client. Begin CPR immediately. This is also an evidence-informed intervention because a delayed response results in poor outcomes as per the research. The client has no pulse, their chest is not rising, and they are not responsive. As a nurse you need to make a clinical judgment on how to act based on these cues. Example Effective (or indicated) interventions are actions that are adequate to produce the intended result and help the client. Type of Intervention Activity: Check Your Understanding An interactive H5P element has been excluded from this version of the text. You can view it online here: https://pressbooks.library.torontomu.ca/ assessmentnursing/?p=133#h5p-7 Attribution statement for Figure 1.2 Authors: Spielman et al. Publisher/website: OpenStax Book title: Psychology 2e. Publication date: Apr 22, 2020 Location: Houston, Texas. Book URL: https://openstax.org/books/psychology-2e/ pages/1-introduction Section URL: https://openstax.org/books/ psychology-2e/pages/1-2-history-of-psychology. Textbook content produced by OpenStax is licensed under a Creative Commons Attribution License 4.0 license. References Bennett, M., & Shangreaux, C. (2005). Applying Maslow’s Hierarchy Theory. First Peoples Child & Family Review: a Journal of Innovation and Best Practices in Aboriginal Child Welfare Administration, Research, Policy & Practice, 2(1)89-116. https://doi.org/10.7202/ 1069540ar Bouzenita, A. I. & Wood Boulanouar, A. (2016). Maslow’s hierarchy of needs: An Islamic critique. Intellectual Discourse, 24(1), 59-81. Francis, N.H. & Kritsonis, W.A. (2006). A brief analysis of Abraham Maslow’s original writing of self-actualizing people: A study of psychological health. Doctoral Forum: National Journal of Publishing and Mentoring Doctoral Student Research, 3(1), 1-7. 30 | Introduction to Health Assessment for the Nursing Professional - Part I Gambrel, P., & Cianci, R. (2003). Maslow’s hierarchy of needs: Does it apply in a collectivist culture. The Journal of Applied Management and Entrepreneurship, 8(2), 143–161. James, A., & Lunday, T (2014). Native birthrights and Indigenous science. Reclaiming Children and Youth, 22(4), 56-58. Maslow, A. (1943). A theory of human motivation. Psychological Review, 50(4), 370-396. https://doi.org/10.1037/h0054346 Priorities of Care | 31 Guiding Approaches of Health Assessment The guiding approaches of health assessment refer to specific conventions of when and what type of health assessment to perform. For example, how often should you perform an assessment on the client? What type of assessment should you perform and how comprehensive should it be? Approaches always depend on the context of the situation. As you become more experienced, you will also be able to pick up on cues that require additional assessment. Health Assessment Frequency The frequency of a health assessment is determined by the setting (e.g., primary care, long term care, acute care) and the health and clinical status of the client. The frequency of a primary care visit depends on the client’s age and their health status and needs. For example, guidelines have been established for the frequency of well-baby and childhood visits and maternal health visits. Also, clients with complex healthcare needs (such as multiple morbidities) will need to see their primary care practitioner more often than a healthy adult. The frequency of assessment in a long-term care setting is often determined by concerns voiced by the client, the personal support worker (PSW), or the registered practical nurse (RPN). PSW and RPN typically have more 1:1 contact with clients in long-term care settings and will draw the registered 32 | Introduction to Health Assessment for the Nursing Professional - Part I nurse’s attention to concerns that may require further assessment. The frequency of assessment in acute care (such as medical or surgical units) will be at least every four hours. In critical care, this frequency is increased to usually every 1–2 hours at least. Clients in critical care are usually on a monitor in which their heart rhythm and vital signs such as oxygen saturation and heart rate are constantly monitored and alarm bells will signal if there is an abnormal change. Although there may be a standard for the frequency of assessment based on the unique population you care for or the institution policy, you must be aware that escalation of care and increased frequency may be needed based on the nurse’s assessment and the client’s clinical status. For example, at times clients may require constant observation (e.g., post-surgery, in critical care environments, a client who is unstable or may show signs of deterioration, or a client in mental health distress with suicide ideation or post-attempt). Health Assessment Types There are several ways to describe health assessment types. In this chapter, we refer to four types including: primary survey; focused assessment; head-to-toe (abbreviated version); and complete health assessment. As per Table 5.1, the type of health assessment to be performed is determined based on the context of the situation. Table 1.5: Types of health assessment Guiding Approaches of Health Assessment | 33 Type of Assessment Recommendations Primary survey Airway (patency) Breathing (respiratory rate, work of breathing, oxygen saturation) Circulation (pulse rate/rhythm, BP, urine output) Disability (level of consciousness, speech, pain) Exposure (temperature, skin integrity, pressure injuries, wounds, dressings, drains, lines, ability to transfer/mobilise, bowel movements) (Douglas et al., 2016) According to current recommendations, all assessments should begin with a primary survey because this structured assessment helps nurses recognize and act on signs of clinical deterioration (Considine & Currey, 2014) that are correlated with death (Douglas et al., 2016). A primary survey collects data in order of importance, and it is aligned with most institutions’ rapid response systems (Considine & Currey, 2014). This recommendation marks a change from the tradition of beginning an assessment with vital sign measurement (Considine & Currey, 2014) or doing a head-totoe assessment. A primary survey will help you determine if urgent intervention is needed or whether you should perform a focused assessment or a head-to-toe assessment. This change in assessment practice is still relatively new. Thus, you may encounter healthcare professionals who are not familiar with this shift in practice and the primary survey. It can provide an opportunity for discussion and learning. 34 | Introduction to Health Assessment for the Nursing Professional - Part I Focused assessment An assessment that is specific to a health concern/reason for seeking care. This type of assessment is performed in all areas of care (e.g., primary care, emergency, longterm care, medical, surgical). Because of its specificity, it usually involves a focus on a limited number of body systems based on the health concern, similar to an episodic database. For example, a client’s reason for seeking care may be an “achy knee.” Thus, the nurse’s assessment will be focused on the musculoskeletal system. Another example may be chest pain. Because there are multiple causes of chest pain, you may need to do a cardiac, respiratory, and musculoskeletal assessment. Another example is a follow-up assessment: a client may have been prescribed a new medication for high blood pressure and needs a follow-up assessment a couple of weeks later to determine the effects. Guiding Approaches of Health Assessment | 35 Head-to-toe assessment (abbreviated) A head-to-toe assessment follows a cephalocaudal approach, assessing several body systems, and provides an overview of the client’s current health status. Typically, a head-to-toe assessment should take about 10 minutes and should be performed at the beginning of your shift and when you first interact with a client. There are variations of this assessment based on the client situation, reason for seeking care, and institution/unit. A head-to-toe assessment usually includes attention to overall wellbeing/needs, pain, vital signs, specific assessments related to neurological, cardiovascular, peripheral vascular, skin, respiratory, gastrointestinal, genitourinary, activity/rest, and wounds/dressings, IV sites, drains/tubes, and oxygen. Based on the collected data, this type of assessment may influence the need for a more focused examination of a specific body system. For example, you may notice the client has a bloated and hard abdomen. Based on these cues, you should complete an abdominal assessment. A more complete assessment/ head-to-toe may be needed in certain situations when a comprehensive assessment is warranted (see next section on complete health assessment). 36 | Introduction to Health Assessment for the Nursing Professional - Part I Complete health assessment A complete health assessment is similar to a head-to-toe assessment, but it is more comprehensive. It involves a subjective and objective assessment of all body systems. It provides a full overview of the client’s current health status. A complete health assessment may take 30–60 minutes depending on the client and the complexity of their health issues. It may be performed for several reasons, often when clients have complex care needs. It is often performed upon admission to a long-term care home or rehabilitation, and sometimes in a primary care setting with new clients. It may also be performed in acute settings when a client has complex health problems and diagnoses have been problematic. This kind of assessment can vary based on the client situation, developmental stage, reason for seeking care, and institution/unit. Clinical Tip When you are new to a work environment, you should inquire about the typical conventions surrounding assessment frequency and type. It is also always helpful to ask your clinical instructor/preceptor about their approach to assessment. When conducting these assessments, it is important to assess the client’s level of consciousness and level of orientation. New onset disorientation and/or a decrease in level of consciousness are important cues that could indicate clinical deterioration and thus, require immediate intervention. If not yet completed, a primary Guiding Approaches of Health Assessment | 37 survey should be done and findings shared with the physician or nurse practitioner. Level of consciousness is the client’s state of awareness and response to stimuli (voice/sound or physical). Their level of consciousness is described as: Alert and oriented: This means that the client is awake (or easily arouses to your voice), engages appropriately in interactions with you, responds appropriately to your questions, and oriented to person, place, time, and self. Confused and disoriented: This means that the client shows altered cognition such as difficulty in memory retention, difficulty following commands, uncertain about the environment around them, inattention, and shows signs of disorientation in terms of person, place, time, and self. They may have delayed or inappropriate/incorrect responses to your questions. Lethargic: This means that the client is slow/sluggish to arouse to stimuli. For example, you need to say their name loudly or multiple times or physical shake their arm. They are sleepy, lack energy, slow to respond to your questions, but answers appropriately and are oriented. Obtunded: This means that the client has a significant impairment in their level of consciousness and requires a significant and continuous stimuli (loud voice, vigorous shaking of the arm). They have difficulty to respond because of the impairment, need constant coaxing to respond, can only answer very simple questions with one word responses that are difficult to hear and understand. Without stimuli, they will immediately return to sleep. Unconsciousness: This means that the client does not respond to any stimuli and has no purposeful motor responses. Level of orientation is assessed by asking the client questions related to: 38 | Introduction to Health Assessment for the Nursing Professional - Part I Place (questions to ask: Do you know where you are? They may know they are in a hospital because of the room. Thus, you may probe with the question, do you know what hospital you are in?). Time (questions to ask: Do you know what date it is? Do you know what day of the week it is? Do you know what month it is? Do you know what year it is?). Person (question to ask: Do you know who I am? They may say “yes”, but you should probe with the question, can you tell me who I am? They may be able to identify you as a nurse, but forget your name in some cases). Self (question to ask: Do you know who you are? If they respond “yes”, you should probe with the question, can you tell me your name?). A normal response is that the client is oriented to place, time, person and self. If they are disoriented, you indicate what they are disoriented to. You may indicate oriented to place, person and self, disoriented to time. It is important to consider context when assessing level of orientation. For example, a client may not be aware of the specific date, but knows the day of the week or month. Activity: Check Your Understanding An interactive H5P element has been excluded from this version of the text. You can view it online here: https://pressbooks.library.torontomu.ca/ assessmentnursing/?p=135#h5p-8 Guiding Approaches of Health Assessment | 39 References Considine, J., & Currey, J. (2014). Ensuring a proactive, evidencebased, patient safety approach to patient assessment. Journal of Clinical Nursing, 24, 300-307. https://doi.org/10.1111/jocn.12641 Douglas, C., Booker, C., Fox, R., Windsor, C., Osborne, S., & Gardner, G. (2016). Nursing physical assessment for patient safety in general wards: Reaching consensus in core skills. Journal of Clinical Nursing, 25, 1890-1900. https://doi.org/10.1111/jocn.13201 40 | Introduction to Health Assessment for the Nursing Professional - Part I Health Promotion Health promotion is an integral element of health assessment and part of the nurse’s role. Public Health Ontario (2021) describes health promotion as a “process of implementing a range of social and environmental interventions that enable people and communities to increase control over and to improve their health.” An important part of this statement are the words “enable” and “control” because health promotion is focused on promoting the agency of the client. Health promotion is an important component of preventing disease. Health is a resource for everyday living, meaning that health is needed for social, economic, and personal prosperity and growth (Ottawa Charter for Health Promotion, 1986). As a nurse, you should create a space where individuals and communities feel empowered with the capacity to act on what is important to them to enhance their health. As part of the Ottawa Charter for Health Promotion, the Government of Canada (1986) specified that health promotion includes attention to the following elements: Peace and stable ecosystem along with social justice and equity. Education, food, income, and healthy living. Sustainable resources. Healthier choices and avoidance of harmful products. The following sections describe the three broad approaches to health promotion: Behavioural. Relational. Structural. Health Promotion | 41 References Government of Canada (1986). Ottawa charter for health promotion: An international conference on health promotion. https://www.canada.ca/en/public-health/services/ health-promotion/population-health/ottawa-charter-healthpromotion-international-conference-on-health-promotion.html Public Health Ontario (2021). Health promotion. https://www.publichealthontario.ca/en/healthtopics/health-promotion 42 | Introduction to Health Assessment for the Nursing Professional - Part I Behavioural Health Promotion A behavioural health promotion approach focuses on lifestyle and behaviours at the individual level. For example, behavioural health promotion strategies could include healthy eating, smoking cessation, reducing alcohol consumption, or exercise programs. This approach to health promotion is based on the ideology of choice – the assumption or belief that people choose their health behaviours. Therefore, healthcare providers work collaboratively with clients to help them build life skills that address unhealthy behaviours, for example by providing information and/or education. It is important to note that this health promotion approach, although common, has been critiqued for reinforcing victim blaming, an approach that is devoid of contextual understanding and instead emphasizes agency. It has also been critiqued for neglecting the social context in which people live, including the social determinants of health. Example An RN working in a diabetic clinic offers educational sessions to clients with Type II Diabetes on healthy eating to promote balanced blood sugar levels. This is considered a behavioural approach because it focuses on the behaviour of the individual with no consideration of context. For example, this approach does not consider contextual factors such as whether the client has access to healthy food. Behavioural Health Promotion | 43 Relational Health Promotion A relational health promotion approach emphasizes social change at the relational level, meaning the relationships between people, places, environments, spaces, beliefs, meanings, and events. For example, relational health promotion strategies could include pesticide restrictions, family-centred interventions, and bike rallies for persons living with HIV/AIDS. Here, health promotion emerges in the relations between social beings and their surrounding environments. This approach is broader than a behavioural approach because it extends beyond the individual. Example An RN is working in occupational health at a large automotive distribution plant and implements an initiative to install HEPA filters in spaces with many employees to reduce the transmission of disease and enhance air quality. This is considered a relational approach because it focuses on the interrelationship between individuals and their environment. 44 | Introduction to Health Assessment for the Nursing Professional - Part I Structural Health Promotion A structural health promotion approach focuses on structural aspects of health and wellbeing. In other words, it addresses policies and practices that affect health at a broader community level, such as systemic discrimination. For example, structural health promotion strategies may include advocating for access to traditional Indigenous healing options in healthcare, campaigning government for publicly accessible addiction services, and creating a transportation program for underserviced communities. This approach to health promotion recognizes that broader social structures play an important role in health, and that one’s participation and access within a community are shaped by one’s social location. The goal is to dismantle the (often hidden) social processes that contribute to the maintenance of social exclusion and to actively promote health equity. Example A Street Nurse implements a mailbox program for clients with no fixed address and actively advocates for more subsidized housing locally. This is considered a structural approach because it attends to the broader needs of the community while advocating for systemic change. Structural Health Promotion | 45 Health Determinants The Ottawa Charter for Health Promotion from the 1980s remains relevant, but in the 1990s there was a shift to a more expansive understanding of health determinants. See Table 1.6 for some examples of health determinants. Table 1.6: Health determinants. (adapted from the Canadian Public Health Association, 1996). 46 | Introduction to Health Assessment for the Nursing Professional - Part I Health determinants Considerations Healthy child development. Assessment of healthy child development focuses on the physical, cognitive, and emotional development of the child and whether their needs are being met and developmental milestones are being reached. Lifelong learning. This type of learning involves the personal and professional pursuit of knowledge. It can involve developing job skills and improving employability, and thus socioeconomic stability. It may also inspire personal development and foster a continual pursuit of knowledge even into older adulthood Absence of racism and discrimination associated with culture, gender, and sexual orientation. Discrimination and racism can negatively affect a person’s health and wellbeing. Therefore, you should assess for the presence of these in a client’s life and how it affects them. A life free of violence. A life free of violence positively influences health and wellbeing. It is important to be aware of the negative effects of violence on a person’s life and how you can screen and assess for it. Work opportunities and adequate income. Access to work opportunities supports an individual’s development over the course of their life and also provides access to adequate income. Limited access to these opportunities can have negative effects on health and wellbeing. Health Determinants | 47 Healthy lifestyles (nutrition, activity/exercise, sleep/rest, coping and stress management, and smoke free). A range of lifestyle factors can negatively affect health and wellbeing and lead to certain disease processes. Inquiring about these factors is part of many assessments. Healthy, social relationships. Healthy, social relationships are positive health determinants throughout all life stages. These can include parenting relationships, friends, work, and intimate partner relationships: all of these can support development and quality of life. Protection from infectious diseases and environmental hazards. Living in an environment free from and/or protected from infectious diseases and environmental hazards is important to overall health and wellbeing. References Canadian Public Health Association (1996). Action statement for health promotion in Canada. https://www.cpha.ca/actionstatement-health-promotion-canada 48 | Introduction to Health Assessment for the Nursing Professional - Part I Integrative Approach to Health Promotion and Assessment As a nurse conducting a health assessment, you have an obligation not only to document and respond to the data you yield through your health assessment, but also to offer guidance to your clients. An integrative, individualized, and adapted approach to health promotion means that you partner with clients to identify their needs. You may apply all three approaches – behavioural, relational, and structural – to health promotion. For example, some situations may call for a behavioural approach: perhaps the client is seeking strategies to reduce their cholesterol. Other occasions may call for a relational approach, such as working with a family experiencing a loss; still others may require a structural approach, such as helping a client complete application forms to cover their medication costs. All of the health promotion approaches and strategies rely on the nurse’s assessment skills and their capacity to prioritize what is important to the client, their family and community in that particular moment. Although health determinants remain relevant, Gewurtz et al. (2016) also proposed approaching health promotion by focusing on “the integration of physical, mental, social and spiritual components of health and well-being. … [within the context of the person’s] patterns of daily activity” (p. e205). This marks a change from the traditional prescriptive nature of past approaches, which neglected to truly engage the client as an expert in their own lives – it also includes considering the client’s daily patterns of activity that should be the driving force of health promotion interventions. An effective and integrated health promotion approach that is shaped by the client’s daily patterns of Integrative Approach to Health Promotion and Assessment | 49 activity, will require that you understand the person’s day-to-day life and what is important to them. Therefore, when collaboratively developing a health promotion intervention with a client, your assessment should include questions like: Tell me about your day-to-day activities. ◦ What does a typical day look like for you? ◦ Who is involved in these activities with you? Have you had any recent changes in your day-to-day activities in the past year? In order to be a healthier you, how would you like these dayto-day activities to be different? Table 1.7 presents an adapted example based on Gewurtz et al.’s (2016) health promotion approach: it is based on patterns of activity. This example is informed by clinical judgment, which requires identifying health-related cues and the identifying of actions to promote a client’s health and wellbeing. As with all interventions, you should engage the client in identifying what is important to them in terms of their health and wellbeing. Table 1.7: Example of health promotion 50 | Introduction to Health Assessment for the Nursing Professional - Part I Client description Clinical judgement Health promotion An international student has moved to a large city to attend their first year of university. They had a close group of friends and family in the small town they grew up in, and now feels lonely. Their day-to-day activities used to be much fuller and they used to feel engaged, and now they just go to class and study. The nurse recognizes the cues of missing a social group. The student’s activity patterns have been disrupted, leading to loneliness and disengagement. To further analyze these cues, the nurse should explore what other activities the student used to do where they grew up and what activities they may enjoy here. Health promotion interventions should be collaboratively cocreated with the student based on their needs and wants. Interventions might include connecting with their old social circle via social media/videoconference, and also developing new patterns of social activities at the university, for example by joining extracurricular groups. Clinical Tip A focus on health promotion is important in all healthcare settings including primary care settings and hospital/acute care settings. Although health promotion is categorized as a third-level priority of care, you should integrate knowledge of health determinants into all assessments. A focus on health promotion can help promote client engagement and overall health and wellbeing while reducing negative effects. Integrative Approach to Health Promotion and Assessment | 51 References Gewurtz, R., Moll, S., Letts, L., Lariviere, N., Levasseur, M., & Krupa, T. (2016). What you do every day matters: A new direction for health promotion. Canadian Journal of Public Health, 106(2), e205-e208. https://doi.org/10.17269/CJPH.107.5317 52 | Introduction to Health Assessment for the Nursing Professional - Part I Clinical Judgement Activity Read the following case study and begin to work through the clinical judgement activity as the case unfolds. A 20-year-old client was brought into the emergency room (ER) by their roommate with abnormal vital signs. The client had a rapid heartbeat of 160 beats per minute, chest pain, shortness of breath with elevated respiration rate of 32 breaths per minute that are shallow and rapid. The client arrived at the ER sweating, shaking, stating they feel nauseous, chills, lightheaded, tingling sensation in their fingers, and as if they are going to faint. The paramedics were unable to get an O2 saturation reading due to the client’s hands shaking and said the last blood pressure (BP) was elevated at 150/ 92 mmHg. The client’s friend is frantic in the waiting room and calling the client’s parents. An interactive H5P element has been excluded from this version of the text. You can view it online here: https://pressbooks.library.torontomu.ca/ assessmentnursing/?p=400#h5p-10 After the healthcare team provided treatment and asked the client a series of health history questions, they concluded the client had a panic attack. After 20 minutes, the client’s vital signs began to stabilize: heart rate 100 beats per minute, respiration rate 22 breaths per minute, BP 130/82, and O2 rate of 96%. The client shared they had been experiencing a lot of stress at school because their midterm exams are next week. The client hasn’t been sleeping, had been drinking a lot of coffee to stay up to study, and Clinical Judgement Activity | 53 had just broke up with their partner. The client stated they had never had a panic attack before, but that their mother used to have them when she was younger. An interactive H5P element has been excluded from this version of the text. You can view it online here: https://pressbooks.library.torontomu.ca/ assessmentnursing/?p=400#h5p-11 Generating solutions involves identifying the various options (actions and interventions) to address the abnormal findings/cues. This may involve identifying which solutions are indicated, unrelated, or contraindicated. Drag the following actions and interventions in the appropriate category before Checking your answer. An interactive H5P element has been excluded from this version of the text. You can view it online here: https://pressbooks.library.torontomu.ca/ assessmentnursing/?p=400#h5p-12 Health promotion is an integral element of health assessment and focuses on promoting the agency of the client. An interactive H5P element has been excluded from this version of the text. You can view it online here: 54 | Introduction to Health Assessment for the Nursing Professional - Part I https://pressbooks.library.torontomu.ca/ assessmentnursing/?p=400#h5p-13 Clinical Judgement Activity | 55 Key Takeaways Health assessment involves collecting subjective and objective data and must be performed within a nurse’s scope of practice. Clinical judgment is an important component of health assessment resulting in the decision whether or not to act/ intervene, and if action is required, what action. Prioritizing care in nursing is informed by Maslow’s Hierarchy of Needs, as well as priorities of care (first, second, or third), and should also consider the client’s wishes. Guiding approaches to health assessment include types of assessment such as primary survey, focused assessment, abbreviated head-to-toe assessment, and a complete health assessment. Health promotion is an integral element of health assessment informed by behavioural, relational, and structural approaches. 56 | Introduction to Health Assessment for the Nursing Professional - Part I CHAPTER 2 - INCLUSIVE APPROACHES TO HEALTH ASSESSMENT By Dr. Annette Bailey, Dr. Oona St-Amant, Dr. Erin Ziegler, Dr. Lisa Seto Nielsen, Nada Savicevic, Paul Petrie, Evan Accettola, Mahidhar Pemasani, Alexis Andrew, Riddore Creer, Michelle Hughes, and Dr. Jennifer Lapum French translation version available: https://pressbooks.library.torontomu.ca/ evaluationinfirmiere/#main Chapter 2 - Inclusive Approaches to Health Assessment | 57 58 | Introduction to Health Assessment for the Nursing Professional - Part I Learning Outcomes Describe the concept of inclusive health assessment. Define key principles of inclusive health assessment. Outline an anti-oppressive approach to inclusive health assessment. Learning Outcomes | 59 Introduction A health assessment is a “felt” experience for clients. Pause for a moment and put yourself in a client’s shoes. Imagine seeking care and having the nurse diminish your feelings, make you feel unimportant, and exclude you from the care process. How would this make you feel? Probably disrespected, disengaged, and that you don’t matter – maybe even silenced. Now, imagine the alternative: the nurse values your feelings, perspectives, experiences, and considers what is important to you. How would you feel? Probably included, respected, and engaged. The difference here is between health assessments that are exclusive/oppressive versus inclusive/liberating. Learning to conduct a health assessment is an important part of nursing education and practice. Health assessments help nurses understand the health needs of each client and set priorities for their care. Acquiring this understanding requires: objective knowledge, which is obtained through assessment techniques and skills. subjective knowledge, which is obtained through empathetic, relational, and interactional skills. During a health assessment, you will need to communicate and engage critically and empathetically with each unique client to understand how to care for them in relevant and holistic ways. We are all different, and our illness experiences are informed by, and are as unique as, our social experiences, so you cannot apply a one-size-fits-all care plan. Individual health assessments are important to help you understand each client and tailor a unique plan for them. You will need to embrace all aspects of the client’s humanity and be mindful and attentive to any personal and 60 | Introduction to Health Assessment for the Nursing Professional - Part I unconscious biases that may negatively influence your views and interactions with them – this is what is meant by an inclusive health assessment. Safe nursing practice requires an inclusive approach to health assessment. Nurses are expected to protect the physical and psychological safety of clients. If clients have experienced trauma in the past, they may have psychological and physiological reactions (Cohen et al., 2006) that affect how they engage with health professionals and health interventions. It is especially important to protect the psychological safety of clients who have experienced racial or social trauma, or any type of trauma for that matter. The ongoing global social justice movement has brought to light how experiences with systemic oppression – especially discrimination and racism – lead to socioeconomic disparities that eventually have devastating impacts on health. You must consider this reality during any health assessment. Unfortunately, the healthcare system is not free of discriminatory and exclusionary practices, and as a result, this can make clients feel unsafe. Black, Indigenous, and LGBTQI2SA+ (Lesbian, gay, bisexual, transgender, queer, intersex, Two-spirit and asexual) populations continue to experience inequitable care and access disparities, which can lead to distrust of healthcare providers, including nurses. A health assessment is one of the first points of contact between nurse and client. It can be a critical step where a nurse starts to address the experiences of, and repair the harm done to, these groups and others through assessment approaches that uplift, not oppress. For some time, nurses and other healthcare professionals have been encouraged to consider the cultural experiences of clients. However, it is important to transcend the usual emphasis on culture awareness: you should also include anti-oppressive, humanistic practices in health assessments. This chapter explores what it means to be inclusive during a health assessment, in terms of intent and process. Introduction | 61 Reference Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006). Treating trauma and traumatic grief in children and adolescents. The Guilford Press. 62 | Introduction to Health Assessment for the Nursing Professional - Part I What is an Inclusive Assessment? To answer this question, let us first locate its relevance in the context of social justice. Human existence is defined by differences: different people, experiences, cultures, and perspectives. Social justice is most commonly defined as fairness in terms of opportunities, regardless of differences. Social injustice is rooted in differences and has led to terrible human suffering in our society. These injustices are the greatest point of weakness for humanity and come in many forms including: Racism (e.g., anti-Black, anti-Asian, anti-Indigenous racism) Inequality (e.g., sex, gender, racial inequality) Ageism Ableism Social injustice can lead to social paralysis for some groups in society because of differential access to resources and opportunities, marginalization, exclusion, and discrimination. Social paralysis is a state of social stagnation imposed by inequity and injustice that hinders social and economic progress of groups in society. Social injustice can also fuel what is known as “othering discourse” – discourse that promotes an “us” versus “them” mentality (Inokuchi & Nozaki, 2005). Othering is a process of exclusion and marginalization whereby groups of people are made to seem fundamentally different and inferior from dominant social groups, even to the point of making that group seem less than human. This can make marginalized groups feel unworthy and lead to powerlessness, fear, stress, trauma, and vulnerability to illnesses. From a health perspective, extreme manifestations of social What is an Inclusive Assessment? | 63 injustice can include illnesses such as cancer, heart disease, diabetes, and respiratory disease. For example, researchers have demonstrated that structural injustices related to racism are the root cause of disparities in the prevalence and control of diabetes, as well as diabetes-related deaths, among racial and ethnic minorities (Ogunwole & Golden, 2021) Without understanding the social roots of illness, it can be easy to blame clients for their illness outcomes, or even to perpetuate injustice in how a client is treated, with differential practices of health assessments across clients. All clients need to feel that their health and their health needs matter – and that they matter. Health assessments should make clients feel safe, respected, and engaged. If they feel marginalized or feel that they are being excluded or treated differently, this can foster injustices in their health outcomes, and in the healthcare system more broadly. Inclusive health assessments should be grounded in social justice. Nurses must uphold the humanity of all clients in all aspects of care, regardless of the client’s race, ethnicity, gender, sexuality, age, ability, and any other factor that makes them who they are. Inclusive health assessments are based on four key principles: 1. Treat every health assessment as an act of humanity. What does it mean to be treated like a human being? We all want to be accepted, respected, and feel a sense of belonging. If you make a client feel otherwise, you are engaging in an act of oppression, which can affect human dignity and capacity to grow and transform. It is important to recognize that even though nursing is a caring profession, nurses have the power to oppress. You must acknowledge differences among clients, while committing to dismantle social injustices within healthcare systems that render clients inhumane. 2. Health assessments are not about sameness. Every client is different, so health assessments have to go beyond the “normal” or standardized approaches to physical assessment. 64 | Introduction to Health Assessment for the Nursing Professional - Part I “Normal” is a social construct: a common social idea based on cultural values and relative norms. You need to obtain a nuanced understanding of each client’s unique health and illness experiences and help them move towards a path of healing. A health assessment should be more than a physical assessment: talk with the client to obtain their health history and get to know them. An inclusive health assessment means that you recognize and integrate the client’s unique experiences and knowledge in their care. 3. Examine your own personal biases. Everyone carries biases that are acquired through socialization. These may include biases about different races, cultural practices, body sizes, or religious practices. These biases can affect how you present yourself during a health assessment, and consequently how clients feel and respond in your presence. By learning about your own biases – how they developed and how they influence your actions – you can both understand how they lead to further injustices in nursing practice, and how you can start to unlearn them. 4. Cultivate a safe environment of care. Create an environment where the focus is on what matters to the client. Approach each client with a “spirit of inquiry” (Registered Nurses’ Association of Ontario, 2007, p. 26). Keep an open mind as you learn about the client’s needs and perspectives: accept the client for who they are, value their feelings and experiences, and don’t judge them. A safe space is important for clients to express themselves without fear of being judged and discriminated against. Clients will engage more when they feel they are collaborating with the nurse on a common goal in terms of what is important to the client. Feeling safe promotes self-worth and a feeling of belonging, which are critical outcomes of social justice in the healthcare system. What is an Inclusive Assessment? | 65 Clinical Tip Take a moment to test your own biases by taking the Harvard Implicit Association Test: https://implicit.harvard.edu/implicit/langchoice/ canada.html When you go to this link, you can click on “Background” to learn more about the origins and purpose of this test or click on “Take a demo test” to test your biases. The following diagram (Figure 2.1) shows how these key principles are inter-connected. You should incorporate all of them while engaging in an inclusive health assessment. As discussed above, social justice is central to inclusive health assessment, and is therefore located in the middle of the diagram. Importantly, as indicated, social justice is rooted in anti-oppressive perspectives, as discussed later in the chapter. The dotted line signifies the direct interaction between the practice of inclusive assessment in the healthcare system and its continuing impacts in communities. 66 | Introduction to Health Assessment for the Nursing Professional - Part I Figure 2.1: Principles of inclusive health assessments (illustrated by Levar Bailey) Activity: Check Your Understanding An interactive H5P element has been excluded from this version of the text. You can view it online here: What is an Inclusive Assessment? | 67 https://pressbooks.library.torontomu.ca/ assessmentnursing/?p=546#h5p-38 References Inokuchi, H., & Nozaki, Y. (2005). “Different than Us”: Othering Orientalism, and US middle school students’ discourse on Japan. Asia Pacific Journal of Education, 25(1), 61-74. https://doi.org/ 10.1080/02188790500032533 Ogunwole, S. M., & Golden, S. H. (2021). Social determinants of health and structural inequities—root causes of diabetes disparities. Diabetes Care, 44(1), 11-13. https://doi.org/10.2337/ dci20-0060 Registered Nurses’ Association of Ontario (2007). Healthy work environments best practice guidelines: Professionalism in nursing. Registered Nurses’ Association of Ontario. https://rnao.ca/sites/ rnao-ca/files/Professionalism_in_Nursing.pdf 68 | Introduction to Health Assessment for the Nursing Professional - Part I Moving Beyond Culture in Health Assessment As healthcare professionals, nurses have power. You have power. If not applied carefully, this professional power can make clients feel marginalized or dismissed. In recent years, progressive developments in theoretical perspectives have guided nursing practice toward more humanistic care and considerations for marginalized clients and communities. New concepts have been introduced to help inform clinical judgement, honour the cultural values/beliefs of clients, and support therapeutic relationship building. These concepts include: cultural sensitivity, cultural competence, cultural humility, and cultural safety. They have helped clarify how personal biases can influence health assessments and other nursing interventions, and have also helped many nurses learn how to minimize their own biases. Culture can be defined as the beliefs, practices, and values of a racial/ethnic group; it can also include other dimensions such as gender, sexual orientation, ability/disability, age, class, and language (Greene-Moton & Minkler, 2020; Hughes et al., 2019). Reflect on each client’s culture: What are their cultural beliefs, values, and identity? What should you do once you are aware of a client’s culture and cultural differences? Most importantly, can this understanding of culture help you conduct an inclusive health assessment? The following discussion explores these questions, beginning with Moving Beyond Culture in Health Assessment | 69 an exploration of how four main concepts of culture relate to health assessments. Cultural Sensitivity In nursing, cultural sensitivity focuses on self in terms of the nurse’s awareness and understanding of a client’s culture as well as attitude toward culture (Srivastava, 2007). Cultural sensitivity, therefore, largely rests on the nurse’s ability to be compassionate, considerate, and understanding of clients, including effective communication with clients from different cultures (Foronda, 2008). Cultural Competency In the past, cultural competency has been narrowly operationalized as a checklist of cultural knowledge required by healthcare providers to demonstrate competence when working with various racial and ethnic groups (Curtis et al., 2019; Greene-Moton & Minkler, 2020). A nurse who is culturally competent is able to provide effective care to clients from different cultural backgrounds (Sharifi et al., 2019). However, if you do not know the cultural beliefs and practices of an ethnic group, does that make you culturally “incompetent”? This kind of ambiguity in the concept of cultural competency has led to the urgency of other effective frameworks for nurses to use, including cultural humility and cultural safety. 70 | Introduction to Health Assessment for the Nursing Professional - Part I Cultural Humility Cultural humility is a life-long process of reflection and selfcritique in addressing power imbalances within systems to develop mutually beneficial partnerships and relationships (Tervalon & Murray-Garcia, 1998). Healthcare professionals should engage in continuous, critical reflection on power and privilege, and find ways to interact with clients of different race, sex, gender, age, and ability that don’t perpetuate oppression. Cultural Safety Cultural safety requires that nurses recognize power differentials and broader social structures that affect health equity (Curtis et al., 2019). Nurses must challenge power imbalances in client care, considering the effects of oppression on health (Parisa et al., 2016). Culturally safe practice is essential in addressing health and social disparities and inequities, to ensure equitable and client-centred care. Integration of Concepts Nurses can apply these four concepts of culture to understand cultural differences and embrace respectful ways of interacting with clients from different cultural backgrounds. This can be a starting point for broader considerations of historical, social, economic, and political factors that also shape health inequities (Smye & Browne, 2002). Moving Beyond Culture in Health Assessment | 71 Despite the large body of theoretical work on culture and safe practices, many healthcare professionals continue to be intolerant of differences. So, beyond an understanding of culture, what else is needed for nurses to uphold all the elements of social justice in nursing care broadly and in health assessments specifically? The next section explores how you can apply an anti-oppressive perspective to ensure health assessments are inclusive. This involves confronting and dismantling oppressive practices that are accepted as the status quo in health assessments and the healthcare system more broadly, especially in the care of marginalized groups. Activity: Check Your Understanding An interactive H5P element has been excluded from this version of the text. You can view it online here: https://pressbooks.library.torontomu.ca/ assessmentnursing/?p=548#h5p-39 References Curtis, E., Jones, R., Tipene-Leach, D., Walker, C., Loring, B., Paine, S.-J., & Reid, P. (2019). Why cultural safety rather than cultural competency is required to achieve health equity: A literature review 72 | Introduction to Health Assessment for the Nursing Professional - Part I and recommended definition. International Journal for Equity in Health, 18(1), 174–174. https://doi.org/10.1186/s12939-019-1082-3 Foronda, C. L. (2008). A concept analysis of cultural sensitivity. Journal of Transcultural Nursing, 19(3), 207-212. http://doi.org/10.1177/1043659608317093 Greene-Moton, E., & Minkler, M. (2020). Cultural competence or cultural humility? Moving beyond the debate. Health Promotion Practice, 21(1), 142–145. https://doi.org/10.1177/1524839919884912 Hughes, V., Delva, S., Nkimbeng, M., Spaulding, E., TurksonOcran, R.-A., Cudjoe, J., Ford, A., Rushton, C., D’Aoust, R., & Han, H.R. (2020). Not missing the opportunity: Strategies to promote cultural humility among future nursing faculty. Journal of Professional Nursing, 36(1), 28–33. https://doi.org/10.1016/ j.profnurs.2019.06.005 Parisa, B., Reza, N., Afsaneh, R., & Sarieh, P. (2016). Cultural safety: An evolutionary concept analysis. Holistic Nursing Practice, 30(1), 33–38. https://doi.org/10.1097/HNP.0000000000000125 Sharifi, N., Adib-Hajbaghery, M., & Najafi, M. (2019). Cultural competence in nursing: A concept analysis. International Journal of Nursing Studies, 99. https://doi.org/10.1016/j.ijnurstu.2019.103386 Smye, V., & Browne, A. J. (2002). “Cultural safety” and the analysis of health policy affecting aboriginal people. Nurse Researcher, 9(3), 42–56. https://doi.org/10.7748/nr2002.04.9.3.42.c6188 Srivastava, R. (2007). The healthcare professional’s guide to clinical cultural competence. Mosby Elsevier. Tervalon, M., & Murray-García, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117–125. https://doi.org/ 10.1353/hpu.2010.0233 Moving Beyond Culture in Health Assessment | 73 Moving Toward Anti-Oppression Perspectives in Health Assessments Understanding anti-oppression first requires understanding what oppression is. Oppression Oppression can be defined as the unjustified use of power and privilege to stagnate others socially, politically, and psychologically. Oppression is imposed through demoralizing interactions, discriminatory and exclusive policies/practices, deprivations in access to resources, and publicly propagated stereotyping that create barriers to opportunities, growth, acceptance, and recognition for some groups in society (Banks & Stephens, 2018). Oppression is often framed in opposition to privilege, which can be defined as the unearned, unobstructed access to resources, respect, acceptance, and opportunities awarded to others. Both oppression and privilege are unscripted laws of society that, whether exercised knowingly and unknowingly, govern how we think about and interact with those considered “different.” Oppression is both experienced and felt. Social oppression is structural, meaning it operates at all levels and systems in society, but it is experienced at the individual/group level in the form of powerlessness, trauma, feelings of unworthiness, and an indefensible struggle for recognition and acceptance. This struggle 74 | Introduction to Health Assessment for the Nursing Professional - Part I has yielded a legacy of resilience and resistance in Canada, especially among racialized and Indigenous populations, but the persistent navigation of structural barriers and personal biases has had consequences for these groups, including trauma and illness (Matheson et al., 2019). Anti-Black racism rooted in slavery and anti-Indigenous racism rooted in colonization are known to be illness-inducing forms of oppression. Experiences of anti-Black and anti-Indigenous racism often translate to less educational and job opportunities, increased rates of incarceration, and more exposure to violence. Black and Indigenous children are more likely to be in the child welfare system (Matheson et al., 2019). These experiences increase the possibility of these individuals coming into contact with the healthcare system. Anti-Oppression As you engage with clients in the health and healing process, try to focus on restorative practices. Try to recognize and interrupt the negative consequences of discrimination, racism, colonization, and social injustice. As a nurse, you should operate from a position of cultural sensitivity, cultural competence, cultural humility, and cultural safety, with an overarching professional responsibility to anti-oppressive practices. An anti-oppressive framework of practice is an allencompassing commitment to social justice and the flourishing of human dignity. When you apply an anti-oppressive perspective to a health assessment, you will be acutely aware of the many ways that health inequities can negatively transform the health of clients, their worldviews, and their responses and interactions. This kind of understanding will help ensure that you do not stagnate the client’s healing process, and prompt you to take action to confront Moving Toward Anti-Oppression Perspectives in Health Assessments | 75 discriminatory and exclusive practices within the healthcare system that might hinder the client’s access to equitable care. Contextualizing Culture For example, Black youth in Toronto are disproportionately affected by gun violence deaths and injuries. The social stigma of experiences with gun violence often has negative effects on the care they receive from healthcare providers (Khenti, 2018). When assessing a young Black man with an injury, a nurse who is aware of the concepts of culture will understand that race puts the client at risk for this type of injury. From an anti-oppressive perspective, the nurse further understands that racial inequities and social stigma associated with this type of injury may affect healthcare workers’ views and interactions with this young man and put him at risk for discriminatory care. Awareness of this possibility might prompt the nurse to obtain information needed to help advocate for health resources for the client, and also to support all members of the healthcare team in providing accessible and empathetic care. As you conduct a health assessment from an anti-oppression perspective, you should consider how structural barriers and internalized powerlessness resulting from oppression can 76 | Introduction to Health Assessment for the Nursing Professional - Part I silence the voices of marginalized clients and prevent them from advocating for themselves in the healthcare system. Recognizing how to collaborate with these clients to advocate for health needs is an important part of an anti-oppressive approach to health assessments. Always be aware that feelings of disrespect and unworthiness are common consequences of social oppression, so it is critical that you remain professional and respectful to clients of diverse lived experiences in all interactions. Activity: Check Your Understanding An interactive H5P element has been excluded from this version of the text. You can view it online here: https://pressbooks.library.torontomu.ca/ assessmentnursing/?p=550#h5p-40 References Banks, K. H., & Stephens, J. (2018). Reframing internalized racial oppression and charting a way forward. Social Issues and Policy Review, 12(1), 91-111. https://doi.org/10.1111/sipr.12041 Khenti, A. A. (2018). Three decades of epidemic black gun homicide victimization in Toronto: Analyzing causes and consequences of criminological approach. (Doctoral dissertation). https://yorkspace.library.yorku.ca/xmlui/handle/10315/34979 Matheson, K., Foster, M. D., Bombay, A., McQuaid, R. J., & Anisman, H. (2019). Traumatic experiences, perceived discrimination, and psychological distress among members of various socially marginalized groups. Frontiers in Psychology, 10, 416. https://doi.org/10.3389/fpsyg.2019.00416 Moving Toward Anti-Oppression Perspectives in Health Assessments | 77 Practical Considerations and Application of Inclusive Health Assessment In the next section, we focus on examples of clients from three populations (Indigenous, Black, and LGBTQI2SA+) to demonstrate key actions and considerations for inclusive assessments. We chose these groups based on their historical and current experiences with intersecting oppressions and inequities that have impacted on their care in the healthcare system. We recognize that humanistic nursing care goes beyond race, gender, and sexuality. Therefore, as you learn about these three cases, consider what inclusive assessment and anti-oppressive care might look like for other clients who might experience oppression: immigrant clients, elderly clients, or those with a disability, or other differences (related to religion and other forms of culture) that might lead to oppression. 78 | Introduction to Health Assessment for the Nursing Professional - Part I Inclusive Health Assessments with Indigenous Clients Case Application: Joyce Echaquan Joyce Echaquan was a 37-year-old Indigenous woman who died in a Canadian hospital in September 2020. Before she died, she posted a Facebook Live video of a nurse and another healthcare worker demoralizing her with racist slurs, calling her stupid and saying, “she’d be better off dead” (CBC, 2021). https://www.cbc.ca/news/ canada/montreal/joyce-echaquan-coroner-inquestmay-19-1.6032387 Take a moment to reflect on this. The healthcare workers did not interact with Joyce in a way that uplifted her humanity. How might Joyce’s story have been different? Here are a few strategies to consider when engaging in an inclusive assessment with Indigenous clients: 1. Always try to understand the cultural experiences that affect their health. A nurse interacting with someone like Joyce should be aware that as an Indigenous woman, she may have experienced trauma from colonization, anti-Indigenous racism, and systemic oppression, all of which may have affected her Inclusive Health Assessments with Indigenous Clients | 79 health. The experiences of residential schools have inflicted trauma and abuse on Indigenous children and families, which have resulted in problems including addictions, violence, and suicide (Aguiar & Halseth, 2015; Bourassa et al., 2015). It is important to convey respect for Indigenous clients and their family and empathy for their positionality. 2. When working with Indigenous people, you should recognize their trauma experiences. Ensure your interactions do not aggravate oppression and health disparities within the healthcare system. Healthcare providers have historically contributed to inequities for Indigenous people, and antiIndigenous racism persists today in healthcare systems, which has perpetuated systemic discrimination and barriers in healthcare for Indigenous people (Richmond & Cook, 2016). As a result, many Indigenous individuals are distrustful of Canadian institutions including hospitals. Use inclusive and anti-racist communication: language should put clients at ease and promote belonging. Joyce’s case illustrates how treatment by healthcare workers reinforced social oppression and trauma, and stripped Joyce of her dignity before her death. 3. Try to uphold their self-determination. Consider how historical and current policies affect all aspects of health and acknowledge the inherent right to self-determination among all clients (Richmond & Cook, 2016). Even if you lack this kind of knowledge, you can engage in assessments that uphold selfdetermination. Resist controlling or paternalistic approaches to care and instead prioritize the client’s right to make decisions for themselves. In this context, this means that you need to engage in active learning about: ◦ Systemic discrimination directed at Indigenous Peoples. ◦ The privileging of Western forms of knowledge within healthcare. ◦ Inter-generational trauma caused by historical events like residential schools. 80 | Introduction to Health Assessment for the Nursing Professional - Part I 4. Reflect on your own bias and assumptions about Indigenous people. Reducing inequities in health care for Indigenous people requires being conscious of implicit biases that may affect your view of Indigenous people. Implicit bias toward Indigenous people has become normalized in the healthcare system, such that many are desensitized to it (Wylie & McConkey, 2019). Nurses must engage in critical self-reflection about how their own biases affect their professional practice and the health of their clients (Hughes et al., 2020). When applying an inclusive approach to health with an Indigenous client, you should share the space, listen, and attend to the needs expressed by the client. References Aguiar, W., & Halseth, R. (2015). Aboriginal Peoples and historic trauma: The process of intergenerational transmission. https://www.ccnsa-nccah.ca/docs/context/RPTHistoricTrauma-IntergenTransmission-Aguiar-Halseth-EN.pdf Bourassa, C., Blind, M., Dietrich, D., & Oleson, E. (2015). Understanding the intergenerational effects of colonization: Aboriginal women with neurological conditions—their reality and resilience. International Journal of Indigenous Health, 10(2), 3-20. https://doi.org/10.18357/ijih.102201515113 Hughes, V., Delva, S., Nkimbeng, M., Spaulding, E., TurksonOcran, R.-A., Cudjoe, J., Ford, A., Rushton, C., D’Aoust, R., & Han, H.R. (2020). Not missing the opportunity: Strategies to promote cultural humility among future nursing faculty. Journal of Professional Nursing, 36(1), 28–33. https://doi.org/10.1016/ j.profnurs.2019.06.005 Matheson, K., Foster, M. D., Bombay, A., McQuaid, R. J., & Anisman, H. (2019). Traumatic experiences, perceived discrimination, and psychological distress among members of Inclusive Health Assessments with Indigenous Clients | 81 various socially marginalized groups. Frontiers in Psychology, 10, 416. https://doi.org/10.3389/fpsyg.2019.00416 Wylie, L., & McConkey, S. (2019). Insiders’ insight: Discrimination against Indigenous Peoples through the eyes of health care professionals. Journal of Racial and Ethnic Health Disparities, 6(1), 37–45. https://doi.org/10.1007/s40615-018-0495-9 Richmond, C. A. M., & Cook, C. (2016). Creating conditions for Canadian Aboriginal health equity: The promise of healthy public policy. Public Health Reviews, 37(2), 1-16. https://doi.org/10.1186/ s40985-016-0016-5 82 | Introduction to Health Assessment for the Nursing Professional - Part I Inclusive Health Assessments with Black Clients Case Application: Mireille Ndjomouo Mireille Ndjomouo was a 44-year-old Black mother of three children who died in a Canadian hospital in March 2021. In a video she posted to social media before her death, she begged for help: “it’s as if they’re killing me little by little … I have children. I don’t want to die and leave my children.” She was begging to be moved from that hospital, stating that she had been treated with penicillin despite telling hospital staff she was allergic (World News, 2021). https://www.vice.com/en/ article/pkdnpn/mireille-ndjomouo-posts-videobegging-for-help-in-quebec-hospital-days-before-shedied Mireille was clearly feeling a sense of powerlessness; her voice and her own knowledge of her health needs were not respected. How might Mireille’s story have been different? Here are a few strategies to consider when engaging in an inclusive assessment with Black clients as offered by Dr. Nadia Prendergast, a nurse scholar who focuses on anti-Black racism research: Inclusive Health Assessments with Black Clients | 83 1. Be mindful that experiences with racism in society and the healthcare system affect responses to healthcare professionals. The historical injustices of a 200-year tradition of slavery have caused multigenerational traumas that can make Black clients distrust individuals and interventions within healthcare systems (Kennedy et al., 2007). This distrust may lead them to perceive assessment questions as intrusive. Black clients’ historical experiences with the healthcare system may make them reluctant or abrupt in answering some questions. Some healthcare professionals may view this as aggression – you should avoid perceiving this reluctance as aggression. Instead, explain your reasons for asking the questions and reassure confidentiality. Gauge whether it is safe to ask about their previous experiences with the healthcare system, as this may be seen as interrogating. If the nurse had considered Mireille’s experiences with racism, outcomes might have been different. Try to break down any potential or apparent barriers with consistent acceptance, friendliness, genuine care, and patience. 2. Be aware of your own assumptions about Blackness. Blacks share the common experience of oppression resulting from slavery and present-day racial injustices, but they are not a homogenous group. Media and common myths have led to false perceptions of Blackness, including the false idea that Black people do not feel pain because their nerve endings are different. For example, pain is the most disabling symptom of sickle cell disease, but physicians often deny pain medication to Black sickle cell disease clients, seeing them as drug seekers or drug addicted (Bergman & Diamond, 2013). A Black male youth presenting with pain and asking for morphine might be perceived and treated as a drug addict, when he is actually having a sickle cell crisis. This kind of incorrect assumption can lead to improper assessments and care, as with Mireille. Always invite Black clients to share their own knowledge. Being willing to learn from the client creates an equitable 84 | Introduction to Health Assessment for the Nursing Professional - Part I environment for healing. Culture is exercised and interpreted differently by everyone, so it is unrealistic for you to learn everything about other cultures; instead, try to come from a place of recognition, awareness, and desire to dismantle racism. 3. Be attuned to your own biases about Black clients. Systemic oppression has worked to influence perceptions of Blacks as primitive and unintelligent (Smiley & Fakunle, 2016). Linked with this are biases around people who speak with an accent as being perceived as not intelligent or being less intelligent, as well as the use of gesticulations and loud voice volumes as being signs of mental health, violence, and uneducatedness. These biases can affect how you engage with Black clients – and even when not intentional, Black clients may interpret behaviours that are dismissive and judgemental as racism. Racism manifests in our biases about racialized people as lesser being

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