Environmental and Global Health; End of Life Care

Question 1

What is Environmental Health?

Answer 1

Defined by WHO as: All the physical, chemical, and biological factors external to a person, and all the related factors impacting behaviors
Encompasses the assessment and control of environmental factors that can potentially affect health
Targeted towards preventing disease and creating health-supportive environments

Question 2

Healthy People focuses on six environmental objectives:

Answer 2

Outdoor air
Surface and groundwater
Toxins and hazardous wastes
Homes and communities
Infrastructure and surveillance
Global environment

Question 3

The probability that individuals will be adversely affected by a hazardous substance depends on three major factors:
What is the exposure risk assessment?

Answer 3

1. Its ability to cause harm to humans (toxicity)
2. Whether it enters the body and reaches susceptible organs (routes of entry—ingestion, inhalation, and dermal absorption)
3. The amount that is present
   Exposure Risk Assessment
   - Defined as the process used by policy makers and other regulators to evaluate the extent to which a population may suffer from health effects from an environmental exposure.
   Involves four steps:
   1) Hazard identification
   2) Dose-Response Assessment (based on experiments that look for a correlation between an increase in harmful effects and an increase in quantity of a substance)
   3) Exposure assessment (consideration of the level, timing, and extent of the exposure)
   4) Risk characterization: This last step brings together the information from the first three steps to guide a judgment about the risk of health problems to those who are exposed.

Question 4

Types of Exposures

Answer 4

Chemical
- Carbon monoxide (silent killer, no smell): Correct monitoring devices (some plug into wall, some go along with smoke detectors); Check batteries in device
Primary: education
Secondary: collecting blood samples, ABGs
Tertiary: referring someone exposed to pulmonologists
- Metals
- Pesticides
- Lead: stored in the bone, where it can slowly release over time to cause deleterious health effects long after the actual exposure has occurred.
- Cigarette smoke
Biological Agents
- Bacteria
- Viruses
- Plant and animal contact
- Toxic plants and fungi
- Allergens
Physical Agents
- Heat
- Cold
- Radiation
- Noise
- Vibration
- Falls
- Vehicle crashes
- Violence (gunshot wounds, stabbings)
Psychosocial Factors
- Behaviors after severe weather event or witnessing violence

Question 5

Assessing Environmental Health Risks in Children

Answer 5

Children’s bodies operate differently than adults, potentially increasing their risk for toxic exposure
RR is faster, inhaling more
Digestive absorption is quicker
Immune systems are weaker
Hand washing to prevent spread from soil to food (lead in soil)
Childhood cancer linked to cleaning solutions, air pollution

Question 6

Assessing Environmental Health Risks in Older Adults

Answer 6

Increased age
Chronic Conditions
Increased risk for environmental hazards
- Falls are a part of environmental health (rugs, cords)
Higher burden of absorbed chemicals in their system
- Slower metabolism

Question 7

Environmental Justice

Answer 7

Economically disadvantaged populations and other vulnerable populations are at greatest risk of exposure to environmental hazards
Environmental justice refers to fair distribution of environmental burdens

Question 8

Roles for Nurses in Environmental Health

Answer 8

Knowledge of the role the environment plays in health of individuals, families, and populations
Assess health hazards and make referrals
Use of appropriate risk communication strategies
Understand policies and legislation related to environmental health

Question 9

What is Global Health?
Why is Global Health important to the United States?

Answer 9

• The World Health Organization’s (WHO) classic definition of health is “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”
• The constitution of the WHO further recognized that for everyone a fundamental right is “…the enjoyment of the highest attainable standard of health…as one of the fundamental rights of every human being.”
• The failure to engage in the fight to anticipate, prevent, and ameliorate global health problems would diminish America’s stature in the realm of health and jeopardize our own health, economy, and national security” (IOM).

Question 10

Global Health promotes…
Global State of Health
How is Global Health Measured?

Answer 10

Promotes:
- A civil society
- Social and cultural growth
- Political stability
- Economic sustainability
Encompasses:
- All nations
- All people
Global State of Health
Today…
- The health of many countries is declining
- Longevity is decreasing
Why?
- More difficulty with the control and eradication of communicable diseases
- Illnesses that are associated with maternal, child, and women’s health
How is Global Health Measured?
- Life expectancy
- Based on 2013 estimates worldwide, there is a wide range among countries (40.03 years to 89.63 years)
- Low income countries (LIC) have the lowest life expectancy

Question 11

Nursing and Global Health
Global Health Challenges
Nursing Challenges in Global Health

Answer 11

Nursing plays an important role across the world in:
- Providing care
- Developing population-level interventions
- Conducting needed research on how best to improve health for vulnerable populations
Global Health Challenges
- Human rights
- Ethical and moral dilemmas
- Availability of health-care providers
Nursing Challenges in Global Health
- Being prepared to practice in diverse environments
- Emerging and reemerging communicable diseases
- Provide care to diverse populations
- Focus on evidence-based practice that includes the global community
- Recognition of global learning
- Develop understanding of:
Local communities
National communities
Global communities

Question 12

The Millennium Development Goals

Answer 12

1. Eradicate extreme poverty and hunger
2. Achieve universal primary education
3. Promote gender equality and empower women
4. Reduce child mortality
5. Improve maternal health
6. Combat HIV/AIDS, malaria, and other diseases
7. Ensure environmental sustainability
8. Develop a Global Partnership of Development Source

Question 13

Major Global Health Organizations
Multilateral organizations

Answer 13

Work and funding come from multiple governments
- WHO
- Pan American Health Organization
- UNICEF
- World Bank

Question 14

What does the World Health Organization do?

Answer 14

• Provides technical support and health care services to member nations, with an emphasis on poorer countries.
• Has made the elimination of health disparities its primary goal. It directs and coordinates international health projects, collaborates with other organizations and agencies in health care programs, and monitors and reports on worldwide disease conditions.
• Leading the effort to establish international standards for medications and vaccines.
• Helps run immunization programs, build health care infrastructure, and improve sanitation levels

Question 15

What does Pan American Health Organization do?

Answer 15

• The organization’s primary mission is to strengthen health systems at the international and local level to improve the health and living standards of the population of the Americas.
• AHO monitors the spread of disease and has worked hard to provide childhood immunization and other methods of care to reduce infant mortality.

Question 16

What does United Nations International Children’s Fund (UNICEF) do?

Answer 16

• Concentrates its efforts in the area of maternal and child health. In the past, UNICEF has concentrated on the control of specific communicable diseases.
• While still maintaining that focus, it has expanded into the area of primary prevention.
• Newer efforts are geared toward fresh water and safe food supplies, health education for mothers of children, the education of girls, and immunization programs aimed at reducing or eliminating vaccine-susceptible communicable diseases

Question 17

What does World Bank do?

Answer 17

The organization’s major aim is to lend money to lesser developed countries for improvements in education, health, agriculture, and natural resource management.

Question 18

Bilateral Organizations

Answer 18

Represent a single government that donates aid to countries
Directed toward developing countries
Agency Examples
- U.S. Agency for International Development
- Centers for Disease Control and Prevention: The scope of the agency’s efforts includes the prevention and control of CDs and NCDs, injuries, workplace hazards, disabilities, and environmental health threats. In addition to health promotion and protection, the agency also conducts research and maintains a national surveillance system. It also responds to health emergencies and provides support for outbreak investigations

Question 19

Major Global Health Problems and the Burden of Diseases
Communicable Diseases include…

Answer 19

Tuberculosis (TB)
- Largest cause of death from a single infectious agent
AIDS
- Increasing incidence in adolescents, young adults, and heterosexuals
Malaria
- Affects more than 50% of the world’s population

Question 20

Major Global Health Problems and the Burden of Diseases
Noncommunicable Diseases, Injury, and Violence

Answer 20

Stroke, Cancer, Heart Disease (leading cause), Diabetes, Chronic Respiratory Disease
- 35 million die annually from noncommunicable diseases
Violence
- Mortality and morbidity increase

Question 21

Major Global Health Problems and the Burden of Diseases
Nutrition and World Health

Answer 21

Poor nutrition by itself or that associated with infectious disease accounts for a large portion of the world’s disease burden
Many children around the world are underweight and have multiple micronutrient deficiencies
Improved nutrition is related to stronger immune systems, decreased illness, better maternal and child health, longer life spans, and improved learning outcomes for children

Question 22

Major Global Health Problems and the Burden of Diseases
Natural and Man-Made Disasters

Answer 22

Natural disasters
- Earthquakes, tsunamis, floods, hurricanes, cyclones, droughts
- Typically the poor are the worst hit due to their lack of resources to cope and rebuild
Man-Made disasters
- Bioterrorism attack
- Chemical Emergency
- Radiation poisoning

Question 23

Nursing Needs in Low Income Countries

Answer 23

Education
Food
Safe water
Basic sanitation - WASH HANDS
Maternal child health
Equity
Appropriate technology
Prevention and control of endemic diseases
Appropriate treatment for common ailments and diseases
Provision of essential drugs
Available resources
Primary and secondary prevention

Question 24

Neglected Diseases include…

Answer 24

Sicken and will kill more than one billion each year worldwide
- Cholera
- Shigella
- Lymphatic filariasis (Elephantiasis)
- Leprosy
Pharmaceutical companies are not motivated to develop safe, affordable drugs
- Populations too poor to afford them

Question 25

Emerging and Reemerging Diseases

Answer 25

Influenza
Ebola
Hepatitis C
West Nile
Severe Acute Respiratory Syndrome (SARS)
HIV/AIDS

Question 26

Nursing Roles for Global Health

Answer 26

No longer being trained for one setting
Nurses are mobile, and change is daily
Global health approach teaches nurses to:
- View things from many angles
- Work collaboratively
- View health globally
Worldviews are:
- Full of contradiction
- Diverse
- Open to opportunities to make a difference
Key role of nurses now is education on a global basis
Assessment for health literacy
- Implementation
- Intervention
- Prevention
- Evaluation

Question 27

Communicable Diseases include…

Answer 27

Infectious Respiratory Disease
- Bacterial or viral
- Many preventable through vaccination
Malaria
- Preventable
- Primarily results from exposure that occurred during travel abroad
HIV and AIDS
- Higher among persons 25 to 44
- African American
- Hispanic
- Men
- On the rise in older adults
Diarrheal Disease
- Leading cause of death among children below the age of five
- Fecal-oral route most common route for transmission
- Transmission is usually waterborne, foodborne, or through person-to-person contact

Question 28

Emerging and ReEmerging Communicable Diseases
Emerging:
Reemerging:

Answer 28

Emerging Disease
- One that has appeared in the population for the first time or that may have existed previously but is rapidly increasing in incidence or geographic range
- Some have been eradicated or close to eradication
- New diseases emerging at a rate of one per year
- Severe ARS, West Nile, Ebola, Zika, COVID
Reemerging diseases
- Malaria, TB, bacterial pneumonia, polio in Alabama

Question 29

Infectious Agents and the Cycle

Answer 29

Three key components are needed in the transmission cycle
- Agent
- Host
- Environment
Other parts of transmission include:
- Reservoir: where agent resides
- Mode of Transmission: the method through which the agent leaves its reservoir and enters its host.
- Life Cycle of an Infectious Agent
Agent -> Reservoir -> Portal of Exit -> Mode of Transmission -> Portal of Entry -> Susceptible Host

Question 30

Communicable Disease: Immunity
Types

Answer 30

Passive Immunity
- Short-term resistance
- May be acquired naturally (maternal antibody transfer)
Active Immunity
- Long-term
- Occurs naturally when a person contracts a disease
- Artificial: vaccine

Question 31

Outbreak Investigation

Answer 31

Involves conducting a systematic epidemiological investigation into the sudden increase in the incidence of communicable disease
Public health’s goal is to gather enough information so that measures can be put in place to halt the spread of disease

Question 32

Epidemic Curve: Patterns of Occurrence

Answer 32

• Point Source: the source of the exposure happened at one point in time
• Continuous source: the exposure is ongoing
• Intermittent source: exposure comes and goes

Question 33

Communicable Diseases and Communicability
Breaking the Cycle

Answer 33

Not all diseases caused by an infection are communicable
The communicability of an agent is based on the transmission of the infection from one person to another
Breaking the cycle:
- Prevention
- Immunization
- Surveillance
- Outbreak Investigation: An outbreak investigation, related to CDs, involves conducting a systematic epidemiological investigation into the sudden increase in the incidence of a CD.

Question 34

What is palliative care?
Care team:
Goals of care:
Quality of Life:

Answer 34

Care Team Member
- Majority inpatient care setting
- Can be facilitated at home or at LTACs
Goals of Care
- Importance to patient
Quality of Life Focus
- Physical, Social, Spiritual, and Psychological
*Palliative care focuses on expert assessment and management of pain and other symptoms, assessment and support of caregiver needs, and coordination of care.
*Palliative care attends to the physical, functional, psychological, practice, and spiritual consequences of a serious illness.
*It is a person- and family-centered approach to care, providing people with serious illness relief from the symptoms and stress of an illness. *Through early integration into the care plan for the seriously ill, palliative care improves QOL for the patient and the family.
*Can pursue curative treatment
*Any age at any stage of serious illness

Question 35

What is hospice care?
Care team:
Goals of care:
Quality of Life:

Answer 35

Care Team Member
- All different care settings
- Home assisted living, LTACs, inpatient or hospice house
Goals of Care:
- Maintain at what state they are
- Support patient and family through dying process/bereavement process
Comprehensive Care Principles
- “Normal” part of life
*Less than 6 months, terminally ill
*Hospice is a specific type of palliative care provided to patients with a life expectancy measured in months not years
*Hospice teams provide patients and their families with expert medical care, emotional, and spiritual support, focusing on improving patient and family QOL
*Supports the patient & family through the dying process and the surviving family through the bereavement process
*Provides comprehensive medical and supportive services across a variety of settings
*Based on the idea that dying is a part of the normal life cycle
*Must forgo curative treatment
Requires medical prognosis of 6 months of less

Question 36

Similarities between hospice and palliative care

Answer 36

Improve quality of life for patient with serious illnesses
Provide emotional, spiritual, physical, and social support to effectively manage symptoms

Question 37

Types of Death
Sudden:

Answer 37

Traumatic, sudden, usually in ER, hard to handle
Ex: Heart attack, MVA

Question 38

Types of Death
Steady Decline:

Answer 38

Get diagnosis, then steadily decline over weeks/months
Ex: Pancreatic cancer

Question 39

Types of Death
Chronic Illness:

Answer 39

Lives for years with a chronic disease, then a flare occurs and makes having that chronic illness hard to live with
Ex: COPD

Question 40

Types of Death
Progressive deterioration:

Answer 40

Starts out mild, then progresses
Ex: Alzheimer’s Disease

Question 41

Stages of Death
Weeks
S/S

Answer 41

• Decline in socialization
• Altered mental status
• Decreased PO intake
• Fatigue
• Bedbound
• Unable to complete some ADLs

Question 42

Stages of Death
Days
S/S

Answer 42

• Oliguria/Anuria
• Little to no responsiveness
• Terminal Secretions: “death rattle”
• “Rally” day or “surge”
• Temperature instability
• Tachycardia
• Near-death awareness

Question 43

Stages of Death
Hours
S/S

Answer 43

Cool extremities
Bradycardia
Mottling
Terminal secretions: “death rattle” can hear secretions in lungs
Apnea/Cyanosis
Obtundation: can not wake them up, unresponsive

Question 44

Pain With Death and Dying
Barriers
Healthcare professional

Answer 44

• Knowledge deficit (don’t know that people that are dying are in pain when they can’t express it)
• Pain scales not utilized
• Lack of continuity of care
• Poor communication within interdisciplinary team
• Regulation of controlled substances
• Potential of addiction

Question 45

Pain With Death and Dying
Barriers
Healthcare system

Answer 45

• Accountability of staff
• Length of stay
• EMR
• Insurance companies
• Pharmacy concerns
• Limited access to PCPs

Question 46

Pain With Death and Dying
Barriers
Patients, family, social

Answer 46

• Reluctance to speak up
• Cultural concerns
• Sensory or cognitive impairment
• Perception of complaining and not being a “good” patient
• Fear of addiction
• Older adults assume it is normal to feel this way

Question 47

Pain With Death and Dying
Pain Management
(Signs of increasing pain, Medications, Adverse effects, Effectiveness)

Answer 47

*Team approach
*S/S of increasing pain
- Look at VS, grimacing, moaning
*Medications
- Opioids (morphine) and Nonopioids (Acetaminophen)
*Side effects
- Opioids: Constipation, N/V, pruritus, over-sedating
*Effectiveness
- IV med: reassess in 15-30 min
- Oral: reassess in 1 hour
*Can try nonpharm methods

Question 48

Pain with Death and Dying
Pediatric Pain Management
Reliable cues of pain?

Answer 48

*Infants and children are often undertreated r/t misguided fears of…
- Addiction
- Belief they do not feel pain due to having underdeveloped nervous systems
- Inappropriate knowledge of pham interventions
*Physiological indicators (change in HR, BP, O2 sat) may not give accurate picture of pain
*Facial grimacing and crying may not be reliable
*Withdrawn, irritability, or not engaging with family/healthcare team are more reliable cues
*Talk to parents/caregivers!!!

Question 49

DNR/DNI:
Facility Policy
Legal Guardians
Reversal
Limitations of the order
Family Education/Support

Answer 49

DNR/DNI: Do not resuscitate, do not intubate (don’t have to be together)
*Facility Policy
- Patient comes with it, it has to be followed by the facility
*Legal Guardians
- Who can sign it? Patient or legal guardian
*Reversal
- Legalities, can be done at hospital
*Limitations of the order
- Varies by state
- Varies in whether pt wants resuscitation but not intubation, etc
*Family Education/Support
- Talk to the family

Question 50

Environmental Health Assessment
PACE EH

Answer 50

• Community environmental health assessment: - It is a means by which public health and environmental health professionals and agencies partner with community members, organizations, and each other to identify, prioritize, and address environmental health issues.
• One of the most widely used community assessment methodologies is the Protocol for Assessing Community Excellence in Environmental Health (PACE EH)
• Communities that have implemented PACE EH consider it to be a successful tool for expanding the capacity of health agencies in essential environmental health services; engaging the community in problem-solving; and implementing action plans that use community resources to reduce health risks.
• PACE EH draws on community collaboration and environmental justice principles to involve the public and other stakeholders in:
• Identifying local environmental health issues
• Setting priorities for action
• Targeting populations most at risk
• Addressing identified issues

Question 51

Role of Nursing in Environmental Health

Answer 51

(1) Knowledge of the role environment plays in the health of individuals, families, and populations
(2) Ability to assess for environmental health hazards and make appropriate referrals
(3) Advocacy
(4) Utilization of appropriate risk communication strategies;
(5) Understanding of policies and legislation related to environmental health.
ANA’s Principles of Environmental Health for Nursing Practice With Implementation Strategies.
* Knowledge of environmental health concepts
* The Precautionary Principle: use products and practices that do not harm human health or the environment and to take preventive action in the face of uncertainty.
* Nurses have a right to work in an environment that is safe and healthy.
* Healthy environments are sustained through multidisciplinary collaboration.
* Choices of materials, products, technology, and practices in the environment that impact nursing practice are based on the best evidence available.
* Approaches to promoting a healthy environment respect the diverse values, beliefs, cultures, and circumstances of patients and their families.
* Nurses participate in assessing the quality of the environment in which they practice and live.
* Nurses, other health care workers, patients, and communities have the right to know relevant and timely information about the potentially harmful products, chemicals, pollutants, and hazards to which they are exposed.
* Nurses participate in research of best practices that promote a safe and healthy environment.
* Nurses must be supported in advocating for and implementing environmental health principles in nursing practice.

Question 52

Approaches to Environmental Health
Epidemiological Triangle

Answer 52

Epidemiological triangle which describes the relationship between an agent (exposure), host (human), and environment (the complex setting in which agent and host come together)
* Environment—that brings agent and host together in the places we live, that is, housing, schools, workplaces, recreational spaces, communities, and, ultimately, the world
* Interaction between agent and environment: Environmental assessment determines “Why was the agent present in the environment in such a way that the host could be exposed?”
* Interaction between host and environment: Epidemiology determines: “Who was exposed? When? Where? How?”
* Interaction between host and agent: Epidemiology determines “What disease?”; Lab identifies/confirms agent

Question 53

The Built Environment

Answer 53

• Built environment: Human-made surroundings created for the daily activities of humans, reflects the range of physical and social elements that make up a community
• Poor communities often have a built environment with limited resources, higher pollution, poorer maintenance of buildings, fewer options for outside activities, a smaller selection of goods (including groceries), and limited transportation, all leading to poorer health (e.g., lead poisoning, asthma, cancer)

Question 54

Hazardous Substances
The probability that individuals will be adversely affected by a hazardous substance depends on:
Three pathways or routes of entry:

Answer 54

• The probability that individuals will be adversely affected by a hazardous substance depends on:
  (1) Its inherent toxicity, that is, ability to cause harm to humans
  (2) Whether it enters the body and reaches susceptible organs
  (3) The amount that is present.
• Three pathways or routes of entry—ingestion, inhalation, and dermal absorption
• Time lags, known as latency periods, can interfere with our ability to identify cause-and-effect links and hamper our ability to anticipate and prevent negative health effects (Cancer develops many years after exposure)

Question 55

Exposure Risk Assessment

Answer 55

(1) Hazard identification
(2) Dose-response assessment: based on experiments that look for a correlation between an increase in harmful effects and an increase in quantity of a substance
(3) Exposure assessment: consideration of the level, timing, and extent of the exposure
(4) Risk characterization: brings together the information from the first three steps to guide a judgment about the risk of health problems to those who are exposed.

Question 56

Types of Exposures
Chemical Agents

Answer 56

• Carbon monoxide is produced by combustion and is typically encountered in automobile exhaust and home-heating emissions.
• Specific metals and pesticides affect many body systems, sometimes accumulating in the body and, because they release over time, perpetuating their effects over a long period of duration.
• Lead is stored in the bone, where it can slowly release over time to cause deleterious health effects long after the actual exposure has occurred.
• Blood Lead Level: screen for amount of lead in blood
• Environmental cigarette smoke contains thousands of chemicals, some of which are associated with cancer.

Question 57

Policies to Prevent and Respond to Childhood Lead Poisoning:

Answer 57

• Reduce lead in drinking water in homes built before 1986 and other places children frequent.
• Remove lead paint hazards from low-income housing built before 1960 and other places children spend time.
• Increase enforcement of the federal Renovation, Repair, and Painting (RRP) rule.
• Reduce lead in food and consumer products.
• Reduce air lead emissions
• Clean up contaminated soil
• Improve blood lead testing among children at high risk of exposure, and find and remediate the sources of their exposure.
• Ensure access to developmental and neuropsychological assessments and appropriate high-quality programs for children with elevated blood lead levels.
• Improve public access to local data
  Fill gaps in research to better target state and local prevention and response efforts.

Question 58

Exposure
Biological Agents

Answer 58

• Infectious agents such as bacteria, viruses, and other organisms such as rickettsia.
• Some molds are known to have effects on the respiratory system and possibly other more systemic outcomes.
• Many documented hazards associated with plant and animal contact
• Toxic plants and fungi such as poisonous mushrooms and inedible plants
• Allergens such as dust mites, cockroaches, and pet dander

Question 59

Exposure
Physical Agents

Answer 59

• Injurious exchange of energy
• Heat and cold, all forms of radiation, noise, and vibration
• Physical forms of environmental risk for bodily injury include events such as falls, vehicle crashes, and crush injuries, as well as hazards associated with violence, such as knife or gunshot wounds

Question 60

Exposure
Psychosocial Factors

Answer 60

Communities and individuals that live in fear or experience stress, panic, and anxiety associated with real or perceived threats are subject to psychosocial conditions that affect not only health and safety but also overall well-being

Question 61

Mixed Exposures

Answer 61

• Almost all scenarios that pose environmental risks to health combine more than one threat, and these combinations often act synergistically to raise the level of danger.
• Noise in the presence of some chemicals may result in what is called ototoxicity. Ototoxicity is damage to the inner ear that results due to exposure to pharmaceuticals, chemicals, and/or ionizing radiation.
• Mixing cleaning agents that contain ammonia with others containing chlorine leads to the production of chloramines, which are much more toxic than ammonia or chlorine alone.

Question 62

The Environmental Health History

Answer 62

• The amount of exposure to an environmental risk varies based on the proximity to the exposure
• This reflects two key components of environmental exposure to hazardous substances: time and location.
• At the individual level, an environmental exposure assessment begins with time and place.
• An assessment should include three components: an exposure survey, a work history, and an environmental history
• The exposure survey reviews any exposures past and present as well as exposures for members of the household.
• The work history asks about presence of hazardous substances in the workplace, and the environmental history includes potential exposure within the community.
• Warm handoff: This is used in health care as a means for transferring care between two members of the health-care team

Question 63

Environmental Health and Vulnerable Populations
Children

Answer 63

• Children playing on the ground and floor may spend their time in the most contaminated areas.
• Outdoor soil is often contaminated with heavy metals and pesticides, and hand-to-mouth behavior promotes ingestion of both seen and unseen agents.
• Children near parents who are washing work clothes may be playing amid toxins that have been carried home as particles from the workplace.
• Even toys may pose a risk for exposure to toxins including lead and cadmium.
• Children have ingested substances from unlabeled food containers that have been repurposed to hold chemicals or were stored in an easily accessible place such as under the sink.
• Children have faster rates of absorption of most toxic substances: the toxic action can be deadlier because children have a higher metabolic rate, a faster rate of cell growth, and less developed immune and neurological systems.
• Fetuses affected when a pregnant woman is exposed to toxins (alcohol, environmental tobacco smoke, carbon monoxide)
• Breast milk can constitute an ongoing source of ingested toxins because some toxins will transfer from the mother to her milk
• In agricultural settings, children and adolescents are at risk of injuries from farm equipment and vehicles with an agriculture-related fatality of someone under the age of 18
• In urban settings, there are often limited spaces where children can play, and available play spaces may have faulty playground equipment, as well as exposure to chemical and biological waste or threats of violence (playgrounds: potential for ingestion of canine roundworms, genus Toxocara, found in the intestines of cats and dogs that are shed in the feces)

Question 64

Environmental Health and Vulnerable Populations
Older Adults

Answer 64

• Changes in physical and mental functioning associated with age: Hearing and vision loss, respiratory disease, increased fragility of skin, decreased rates of metabolism, and disorders such as osteoporosis and heart disease.
• Older adults experience increased rates of chronic health conditions, accounting for increased vulnerability to environmental health issues
• Older adults also have higher body burdens of chemicals that have been absorbed over their lifetimes. Some substances accumulate over time in the body, a process known as bioaccumulation.
• These toxic substances are commonly retained in tissues such as bone or adipose (fat) tissue and can become a long-term cause of poor health outcomes including cancer, organ damage (in particular, to the kidneys, heart, and liver), cardiac disease, increased chance of stroke, and neurological, immunological, and hematopoietic disorders.
• Lead is stored in the bone with a half-life (time over which only half of the amount is excreted) of more than 20 years. Its slow release over time is reflected by high BLLs that reach and damage target organs
• Older adults are more vulnerable with the anticipated increase in extreme weather due to climate change
• One of the contributing environmental factors that increases the vulnerability of older adults is a diminished ability to regulate body temperature
• Heat wave: adequate cooling, adequate availability of water for hydration, and an effective method of communication are needed
• In addition to cold injuries and death that can result from lack of heat, many people use space heaters that use fuel such as kerosene (fire hazard), charcoal or wood burning indoors -> carbon monoxide hazard
• Housing codes dictate a minimum temperature that must be achievable if the space is to be legally rented.
• City social services, home visiting care, warning systems and emergency cooling centers, monitoring of older adults and isolated persons during an extreme heat or cold event, and improving communication and awareness among city officials and emergency medical services.

Question 65

Environmental Risks: Air

Answer 65

• Industry and the need for energy have resulted in the emission of toxic chemicals into the air.
• Cities with high dependence on motor vehicles for transport, such as Los Angeles and London, have struggled with severe smog due to emissions from automobiles.
• In the 21st century, the continued emission of CO2 has resulted not only in the warming of the climate but a reduction in the quality of the air

Question 66

Environmental Risks: Ambient Air

Answer 66

• Ambient air is the air surrounding a place or structure and is also referred to as outdoor air.
• Poor ambient air quality is associated with increased mortality rates from pulmonary and cardiovascular disease.
• Scientists devised a mechanism to evaluate the current air quality called the ambient air standard: refers to the highest level of a pollutant in a specific place over a specific period of time that is not hazardous to humans.
• Many outdoor air contaminants originate from major stationary sources, known as point sources: chemical plants, power plants, refineries, and incinerators.
• Pollutants may be generated by transportation sources such as buses, trucks, and cars (on-road) and ships, planes, and construction equipment (off-road), all referred to as mobile sources.
• Area sources include smaller sources of emission such as gas stations, dry cleaners, commercial heating and cooling systems, railways, and waste disposal facilities such as landfills and wastewater treatment operations.
• Clean Air Act (1970): specifies allowable limits, known as the National Ambient Air Quality Standards, for industrial emission of a set of major air pollutants called the criteria air pollutants
• These are carbon monoxide, nitrogen dioxide, ozone, particulate matter, lead, and sulfur dioxide.Ground-level ozone and particulate matter are the greatest threats to human health.
• One way to evaluate the degree of air pollution in a specific area is the Air Quality Index (AQI). The AQI is computed by the EPA based on measures of the five criteria for air pollutants. Good, moderate, unhealthy for sensitive groups, unhealthy, very unhealthy, and hazardous

Question 67

Indoor Air Pollution

Answer 67

• Environmental tobacco smoke, animal dander, cockroaches, and the spores of molds that grow in damp environments.
• Many pollutants exist in the home in the form of house dust, which may also be composed of heavy metals, pesticides, gram-negative bacteria, and chemicals such as phthalates.
• Chemicals associated with the materials used to build homes, such as formaldehyde, are another concern.
• Buildings that are well insulated, tightly sealed for efficient climate control, and lack windows that can be opened by occupants are more likely to retain indoor air pollutants.

Question 68

Potable Water

Answer 68

• The quality of water is a major determinant of the health of a population. Both organic and inorganic contaminants are associated with adverse outcomes.
• Inorganic Water Contaminants
• Lead contaminants (Flint)
• Globally, a major issue related to potable water is organic contaminants that increase the risk for communicable diseases
• The main barriers to the provision of safe drinking water include setting it as a priority, financial capacity, sustainability of the water supply, sanitation, and hygiene behaviors.

Question 69

Epidemic:
Endemic:
Pandemic:

Answer 69

• The term epidemic is used when there is a significant increase in the number of cases than would normally occur.
• Endemic refers to the usual number of cases of a disease that occur within a population.
• Pandemic describes epidemics occurring across the globe.

Question 70

Communicable Diseases and Nursing Practice

Answer 70

• Nurses provide care to patients with a CD and also must incorporate preventive measures in their practice, such as the use of personal protective equipment (PPE) and proper cleaning of patient areas to prevent transmission of these diseases.
• Understanding of CDs at both an individual level and a population level is essential.
• The key is to understand the infectious agents that cause disease, the environment relevant to the transmission of disease from one person to another, and who is at risk for becoming infected

Question 71

Infectious Respiratory Disease

Answer 71

• These diseases are either bacterial or viral.
• Many of these diseases can be prevented through vaccination (required for children in public school) such as vaccines for prevention of chickenpox, diphtheria, and rubella.
• Some of these diseases are seasonal, for example, influenza (flu)
• Flu is seasonal, with a peak in early December and a peak in February.
• Because of the higher mortality rate in vulnerable populations such as children, older adults, and those who are already ill, many hospitals require that all employees receive a flu vaccination.

Question 72

Malaria

Answer 72

• Malaria is a subtropical disease caused by a parasite transmitted through the bite of an infected female mosquito, often referred to as the “malaria vector”
• Malarial infections in the United States are primarily the result of exposure that occurred during travel abroad. In addition, these travelers had not adhered to recommended malaria prophylaxis.

Question 73

HIV/AIDs

Answer 73

• A person infected with HIV may not develop AIDS until 10 to 15 years after the initial infection.
• A negative HIV test within 6 months of the first HIV infection diagnosis is stage 0 and remains 0 until 6 months after diagnosis.
• If a stage-3-defining opportunistic illness has been diagnosed, the stage is 3
• Otherwise, the stage is determined by the CD4 test immunologic criteria based on the CDC case definition guidelines.
• In the U.S., the prevalence of HIV and AIDS is higher among persons in the 25- to 44-year-old age group, those who are African American and Hispanic, and in men.
• Racial disparity is especially apparent in children, with 80% of all pediatric cases being African American or Hispanic
• HIV infection is also on the rise among older adults because of increased longevity of those living with HIV as well as an increase in risky behaviors in this age group
• Certain behaviors increase the risk for transmission of HIV, including men having sex with men, those engaging in injection drug use, and those engaging in unprotected sex.
• UNAIDS 909090: An ambitious treatment target to help end the AIDS epidemic. The three main goals by 2020 were:
• 90% of all people living with HIV will know their HIV status.
• 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy.
• 90% of all people receiving antiretroviral therapy will have viral suppression.

Question 74

Diarrheal Disease

Answer 74

• In low-income countries, it is a leading cause of death among children under 5.
• The most common route for transmission of diarrheal disease is the fecal-oral route.
• Good hand hygiene, especially hand washing, and soap alone can reduce the incidence of diarrheal disease
• Efficient sanitary systems and safe drinking water also play a huge role in preventing diarrheal diseases.
• Pathogens that cause diarrheal disease include viruses, bacteria, and protozoa. Transmission is usually waterborne (e.g., cholera), foodborne (e.g., Escherichia coli [E. coli]), or through person-to-person contact
• Worldwide, rotavirus is the most common cause of diarrheal disease among children. There are now two vaccines available for use with infants.

Question 75

Tuberculosis

Answer 75

• In 1889, the National Tuberculosis Association (now the National Lung Association) realized that TB was preventable and not inherited. Since that time, prevention efforts have resulted in a steady downward trend in the incidence and prevalence of TB
• Between 1988 and 1992, five clusters of TB cases appeared in six hospitals. What stood out about these cases was that the agent M. tuberculosis had mutated (changed) and was now resistant to drugs used to treat active TB (MDRTB).
• With HIV, TB does not always present in a classic manner, and diagnosis was delayed in these cases
• The case fatality rate (CFR) was high. A CFR is determined by taking the number of fatal cases and dividing it by the total number of cases.
• Through careful surveillance of TB, the CDC can determine who is at greatest risk based on numerous factors including race, age, geographical location, and place of birth.
• Index case: first case identified in a particular outbreak.
• Secondary cases: patients who were diagnosed with active TB and who had contact with the index patient.

Question 76

Infectious Agents and the Cycle of Transmission
Agent or pathogen
Infectivity:
Pathogenicity:
Toxigenicity:
Virulence:
Antigenicity:

Answer 76

• The term agent or pathogen refers to the infectious organism that causes the disease such as a virus or bacteria
• Bacteria: Bacterial meningitis, Anthrax Bubonic plague, Tuberculosis, Streptococcal infections
• Rickettsia (bacteria): Typhus, Rocky Mountain spotted fever
• Viruses: HIV, common cold Influenza
• Mycoses (fungi): Candida, Histoplasmosis, Fungal meningitis
• Protozoa: Malaria, Giardia, Toxoplasmosis, Trichomoniasis
• Helminths (parasitic worms): Hookworm, Pinworm, Trichinosis
• Arthropods (ticks, fleas, mosquitoes, lice): Malaria, Dengue fever, Lyme disease, Bubonic plague
• Infectivity: reflects the capacity of an agent to enter and multiply in the host.
• Pathogenicity: which is the capacity of the agent to cause disease in the human host
• Toxigenicity: reflects the pathogen’s ability to release toxins that contribute to disease within the human host
• Virulence: the ability of the pathogen to cause disease
• Antigenicity: the ability of the agent to produce antibodies in the human host

Question 77

Infectious Agents and the Cycle of Transmission
Environment
- Carrier
- Incubating carrier
- Inapparent carrier
- Convalescent carrer
- Chronic carrier

Answer 77

The environment refers to the conditions external to the host and the agent associated with the transmission of the agent.
* The first of these is the reservoir, or where the agent resides: Animals, humans, water (waterborne diseases), food (foodborne diseases), and the air (airborne diseases).
* Carrier: human who is infected but who has no outward signs of disease.
* Incubating carrier: someone who has been infected but has not yet shown signs of the disease
* Inapparent carrier: someone who is infected but does not develop the disease, yet continues to shed the agent
* Convalescent carrier: a person who is infected but who no longer shows signs of acute disease
* Chronic carrier: remains infected with the agent with no sign of disease for a long period of time.

Question 78

Infectious Agents and the Cycle of Transmission
Environment
Mode of Transmission

Answer 78

The method through which the agent leaves its reservoir and enters its host.
* Transmission can occur through water, food, air, vectors, fomites, unprotected sexual contact, or penetrating trauma
* Vectors: usually insects that carry the disease from the reservoir to humans without becoming ill themselves
* Fomite: an inanimate object. An infected host touches the object and sheds the agent onto the object. The agent is then transmitted to the next person who touches the object.
* Aerosol or airborne transmission: The agent is contained in aerosol droplets and is transferred from one human to another or animal to human.
* Oral transmission: The agent is transferred through food or water.
* Zoonotic transmission: The agent is transmitted directly from animals to humans.
* Person-to-person transmission: The agent is transmitted through direct contact between persons, usually through contact with mucous membranes, blood, or saliva.

Question 79

Life Cycle of an Infectious Agent

Answer 79

• The life cycle of the agent or the vector provides added information on the transmission of an infectious agent, including how the agent exits its reservoir (portal of exit), the mode of transmission (water, vector, fomite, etc.), and how the agent enters the host (the portal of entry).
• The agent that causes TB primarily infects the lungs; the portal of exit is coughing. The action of coughing expels the agent from the reservoir (human) into the air. The agent has now left its reservoir and is contained in the droplets expelled from the lungs. The mode of transmission is through the air, so TB is considered an airborne disease. The portal of entry for TB is almost always through the host’s respiratory system.

Question 80

Host Characteristics
Susceptibility
Immunity: humoral, cellular, active, passive
Inherent resistance
Colonization

Answer 80

• The host is the human who is at risk for disease due to exposure to the agent.
• The main characteristic is the susceptibility of the host, that is, the likelihood of becoming infected with the agent.
• This is expressed in terms of the host’s immunity, or resistance to the disease.
  Humoral immunity means that the host carries antibodies to the agent in the blood, and cellular immunity is specific to each type of cell.
• When a person has passive immunity, immunity is transferred from one individual to another.
• Lasts a short time.
• Natural: mother to infant.
• Artificial: transfer of antibodies
• Active immunity is acquired through exposure to the agent.
• It is long-lasting and can last for life, as when a person who had mumps as a child remains immune for the rest of his life.
• Artificial: vaccine
• Inherent resistance. This is the ability of the host to resist the disease independent of antibodies
• Colonization: a person is infected with the agent but has no signs of infection. Colonized hosts are able to spread the disease despite not being apparently ill.

Question 81

Breaking the Chain of Infection

Answer 81

Interventions can be aimed at any point in the cycle of transmission
* Eradicating the vector: pesticides
* Blocking mode of transmission: mosquito nets
* Reduce susceptibility of host: vaccination

Question 82

Outbreak Investigation
Point Source
Continuous Source
Intermittent Source

Answer 82

• An outbreak investigation, related to CDs, involves conducting a systematic epidemiological investigation into the sudden increase in the incidence of a CD.
• Investigators seek to identify who got sick, what made them sick, when they got sick, and at what point it happened.
• The public health team’s goal is to gather enough information so that measures can be put in place to halt the spread of disease.
• These facts are essential to determine what is the best action to take to break the chain of transmission and prevent further spread of the disease to uninfected members of the population.
• An epidemic curve is constructed by plotting on a graph the number of cases (y-axis) based on the date of onset (x-axis)
• Point source: the source of the exposure happened at one point in time
• Continuous source: the exposure is ongoing
• Intermittent source: exposure comes and goes

Question 83

Infectious Agents and Attack Rates
Transmission
Generation Time:
Herd Immunity:
Attack rate and secondary attack rate:

Answer 83

• Transmission can occur from the reservoir directly or indirectly.
• Person-to-person contact is an example of direct transmission and occurs with sexually transmitted infections (STIs)
• Indirect transmission occurs when the agent leaves the reservoir and is transferred to the human host through an indirect means such as a vector or in the case of fomite transmission.
• Generation time: the interval between infection with the agent and the maximum time that the host is infectious, that is, the communicability of the host.
• Community or herd immunity: refers to the immunity of a population to an agent. If a large portion of the population is immune (by vaccine or past infection), that can prevent the spread of the disease to persons in the population who do not have immunity.
• Attack rate: a type of incidence rate; it is calculated using the number of persons who are ill divided by the total number of the population. This is multiplied by a constant (usually 100) and expressed over a certain time period.
• Secondary attack: dividing the number of new cases in a particular group minus the initial case(s) by the number of susceptible persons in the group minus the initial case(s). This is multiplied by a constant (usually 100).

Question 84

Controlling Communicable Diseases

Answer 84

The main focus is to control the spread of disease
* (1) Changing the environment
- Can involve altering or eliminating the reservoir, controlling the vector, applying personal measures of hygiene, and using aseptic technique.
* (2) Inactivating the agent
- Includes the use of physical and chemical agents (heat, refrigeration)
* (3) Increasing host resistance
- Vaccine refers to the immunizing agent used to increase the host’s resistance to viral, rickettsial, and bacterial diseases.
- In the United States, children routinely receive a series of vaccines that protect against measles, mumps, diphtheria, poliomyelitis, and rubella

Question 85

Noncommunicable disease (NCD)
Chronic Disease

Answer 85

• A noncommunicable disease (NCD) is a disease that is not passed from one person to the next through direct or indirect means and is not associated with an infectious agent.
• Chronic disease: refers to either communicable diseases such as AIDS, or NCDs such as diabetes that have a long duration and usually slow progression, require medical attention over time, and/or limit the ability to perform activities of daily living (ADLs)
• According to the WHO there are four main categories of NCDs: cardiovascular diseases (CVD), cancers, chronic respiratory diseases (CRD), and diabetes.
• Nurses in all settings play an important role in prevention of NCDs across the continuum of prevention through primary-, secondary-, and tertiary-level interventions.

Question 86

Noncommunicable Chronic Diseases
Care

Answer 86

• The majority of NCDs cannot be prevented or cured through vaccination or medication; rather, they require maintaining a healthy lifestyle, early diagnosis and treatment, and long-term management.
• The care of NCDs is moving away from an acute care model to a chronic care model in which the disease is managed over time and the focus is decreasing morbidity and mortality associated with NCDs
• Care of an existing NCD should be provided within a secondary and tertiary prevention framework that focuses on early detection and treatment as well as a long-term plan of care aimed at reducing morbidity and mortality

Question 87

Life Expectancy
HALE

Answer 87

• Mortality rates are used to estimate the life expectancy of a group of people.
• Life expectancy is defined as the number of years a person could be expected to live based on the current mortality rates in a specific setting, usually a country.
• Health-adjusted life expectancy (HALE) reflects the average number of years that a person can expect to live in good health by adjusting for disease and/or injury.
• The WHO uses HALEs to measure the average level of health in countries and regions by evaluating population-specific prevalence of disease and injury as well as severity distribution of health states.

Question 88

Premature Death

Answer 88

• NCDs often lead to premature death, that is, a death that occurs earlier than the standard life expectancy.
• Therefore, premature death reflects the number of potential life years lost.
• Premature death is usually expressed as the years of potential life lost (YPLL).
• YPLL is calculated by subtracting the age at which a person dies from their expected life expectancy
• From a population perspective, premature death is calculated based on the number of potential life years lost prior to the life expectancy of the population per 100,000 persons

Question 89

Disability-Adjusted Life Years

Answer 89

• In addition to premature death, most NCDs lead to disability that can affect an individual’s quality of life and productivity.
• A method for quantifying the burden of disease that takes into account both premature death and disability is called the disability-adjusted life year (DALY).
• This is defined as measurement of the gap that exists between the ideal health status of a disease- and disability-free population that lives to an advanced age
• DALY = YLL (Years of Life Lost) + YLD (Years of Life Disabled)

Question 90

The four common risk factors that account for much of the NCDs in our country:

Answer 90

(1) nutrition, (2) physical activity, (3) tobacco use, and (4) alcohol use.

Question 91

Heart Disease and Stroke
Risk Factors

Answer 91

• CVD and stroke are the first and fifth leading causes of death.
• Large regional variations in the burden associated with CVD exist across the U.S. with dietary risk exposures being the largest attributable risk factor related to CVD burden of disease
• Other risk factors include high blood pressure, obesity, tobacco use, high cholesterol, and low levels of physical activity.

Question 92

Cancer

Answer 92

• Second leading cause of death
• Public health efforts to promote increased screening for breast and colorectal cancer have resulted in a decrease in deaths because of early detection and screening, and the length of cancer survival has increased
• Tobacco use is the leading risk factor for cancer with Lung cancer the leading cause of cancer death in both men and women
• Family history, diet, exercise, reproductive history, and alcohol use have all been associated with increased risk for breast cancer

Question 93

Chronic Lower Respiratory Disease

Answer 93

• Includes chronic obstructive pulmonary disease (COPD), asthma, occupational lung diseases, and pulmonary hypertension
• Major risk factor for COPD and other CRDs is tobacco use; others include exposure to air pollutants, chemical fumes, and dust from the environment or workplace.

Question 94

Diabetes

Answer 94

• Two underlying factors that have contributed to the increase in the incidence of type 2 diabetes are changes in lifestyle, especially exercising and diet
• The prevention or delay of the onset of type 2 diabetes can happen through a healthy lifestyle that includes making healthful changes to diet, increasing the level of physical activity, and maintaining a healthy weight.

Question 95

NCD Risk Factors
Behavioral:

Answer 95

Nutrition, Exercise, and Obesity: The main risk factors associated with obesity are poor nutrition and lack of exercise. These two risk factors are linked to numerous other factors at the population level, including changes in population behaviors, environmental factors, and socioeconomic factors.

Question 96

NCD Risk Factors
Environmental:

Answer 96

• Pollutants in the environment increase the risk for asthma, cardiovascular health problems, and cancer
• Tobacco Use: strongly associated with increased risk for adverse health outcomes including cancer, pulmonary disease, and CVD. The single most preventable cause of morbidity and mortality is the use of tobacco.
• Alcohol use: it has the potential to adversely affect health across the life span, including but not limited to injury, breast cancer, hypertension, stroke, liver disease, and brain damage

Question 97

Socioeconomic Risk for Noncommunicable Disease

Answer 97

• Income and social status: Higher income and social status are linked to better health. The greater the gap between the richest and poorest people, the greater the differences in health.
• Education: Low education levels are linked with poor health, more stress, and lower self-confidence.
• Physical environment: Safe water and clean air, healthy workplaces, safe houses, communities and roads all contribute to good health.
• Employment and working conditions: People in employment are healthier, particularly those who have more control over their working conditions
• Social support networks: Greater support from families, friends, and communities is linked to better health.
• Culture: Customs and traditions, and the beliefs of the family and community all affect health.
• Genetics: Inheritance plays a part in determining lifespan, healthiness, and the likelihood of developing certain illnesses.
• Personal behavior and coping skills: Balanced eating, keeping active, smoking, drinking, and how we deal with life’s stresses and challenges all affect health.
• Health services: Access and use of services that prevent and treat disease influences health.
• Gender: Men and women suffer from different types of diseases at different ages

Question 98

Prevention Strategies for Noncommunicable Diseases
Primary, Secondary, Tertiary

Answer 98

• Primary prevention focuses on behavioral change with a strong emphasis on healthy eating and exercise.
• Population-level primary prevention programs help to change barriers to a healthy lifestyle.
• For example, obtaining an adequate level of exercise in an urban setting requires safe streets for walking and/or access to recreational activities.
• Secondary prevention efforts are also associated with reduced morbidity and mortality related to NCD, especially screening
• Examples of screening programs recommended by the CDC for the prevention of NCDs include mammograms and screening for colorectal cancer
• Tertiary prevention efforts aimed at reducing the adverse consequences experienced by a person who has already been diagnosed with a disease.
• The goal is to reduce the morbidity and disability associated with the disease and to prevent premature death

Question 99

Health-Related Quality of Life
Chronic Disease Self-Management

Answer 99

• Health-related quality of life (HRQoL) is a multidimensional construct related to the desired physical and psychological health outcomes for most of the interventions that nurses provide to individuals and families.
• An evidence-based approach to improving HRQoL for persons with NCD is chronic disease self-management (CDSM).
• CDSM is an ongoing process by which individuals with a chronic illness or condition engage in self-management of medications, symptoms, and promotion of their own health, and can be applied to both noncommunicable and communicable chronic disease.
• CDSM requires implementation of health-promotion and health protection strategies
• Extensive research exists related to the efficacy of patient education programs for specific chronic diseases such as asthma and diabetes