ED

Health History, Substance Use, and Violence Assessment

Trigger Warnings & Context

  • Topic areas covered: partner abuse, human trafficking, substance use/abuse, complete health history interview.

  • Instructor alerts students that material may be upsetting; students may step out or use counseling services.

  • Time-constraint: ~1.5-hour class; emphasis on seeing these issues in every clinical setting.

Objective vs. Subjective Data

  • General survey (previous lecture) = objective.

  • Complete Health History = subjective (what the patient says, past & present).

  • Two interview purposes:

    • Wellness visit → explore lifestyle, risk factors, health promotion.

    • Sick visit → focused, deeper dive into present symptoms.

Core Components of a Complete Health History

  1. Biographical Data

    • Name, address, phone, DOB, etc. (often pre-entered via electronic forms).

    • Sex (assigned at birth) vs Gender Identity.

      • Sex determines anatomical risk (prostate, cervix, etc.).

      • Gender identity guides respectful communication (pronouns, chosen name).

      • Rare chromosomal / intersex variations discussed (XX/XY vs genital appearance).

    • Relationship status – maps support system.

    • Ethnicity & race – some disease prevalence differences (e.g., hypertension).

    • Primary language & literacy – crucial for discharge teaching and printed instructions.

    • Occupation – will be probed later for exposures, repetitive motions, exercise built into job, etc.

  2. Reason for Seeking Care (Chief Complaint)

    • Record verbatim and in quotation marks (e.g., "chest pain for 2 hours").

    • Avoid medical jargon/diagnoses.

    • Note top one or two most urgent signs/symptoms for focused visit.

  3. Symptom Analysis – PQRST

    • P = Provocative/Palliative (what worsens or relieves; activity at onset).

    • Q = Quality/Quantity (burning, dull, sharp; mild vs severe).

    • R = Region/Radiation (exact location, spreads?).

    • S = Severity (0–10 scale; instructor’s "run-over-by-a-truck" analogy).

    • T = Timing (onset, duration, frequency, intermittent?).

    • U = Understanding (patient’s perception/meaning, functional impact, fear).

  4. Past Health History

    • Childhood illnesses (e.g., varicella → future shingles risk).

    • Accidents/injuries (fractures, head trauma, burns).

    • Chronic illnesses (asthma, HTN, DM, depression, etc.).

    • Hospitalizations & Operations (where, when, surgeon).

    • Obstetric history (gravida/para, complications; covered deeper in OB course).

    • Immunizations (tetanus every 10 yrs; MMR outbreaks, etc.).

    • Last examination dates (physical, dental, vision, Pap, mammogram).

    • Allergies

      • Differentiate true allergy (rash, hives, anaphylaxis) vs side-effect (nausea).

    • Current Medications

      • Rx, OTC, herbals/supplements (40 % Americans take OTC q48h; herbals not FDA-regulated → unknown constituents).

  5. Family History (1st-degree relatives emphasized)

    • Coronary artery disease (< 55 ♂ / < 65 ♀ early events), HTN, DM, cancer, TB, mental illness, substance abuse, etc.

    • Migrants / non-US born → ask about endemic diseases.

    • Commercial DNA kits can give false positives/negatives; rely on provider-ordered testing.

  6. Review of Systems (ROS) – head-to-toe, subjective only

    • Negative = denies symptoms; Positive = presence of symptom.

    • If covered in PQRST (e.g., ear pain), simply transfer info—avoid duplication.

  7. Functional Assessment / Lifestyle & Psychosocial

    • Self-esteem/finance/education.

    • Activity & Exercise – ADLs (bathing, feeding, toileting, walking) & leisure (gardening, trumpet, reading).

    • Sleep/Rest (patterns, naps, sleep aids, circadian issues).

    • Nutrition (24-hr recall, caffeine, allergies, who shops/prepares food).

    • Interpersonal relationships/support (family, friends, religious groups, workplace, clubs).

    • Spiritual resources (identify needs regardless of nurse’s own beliefs).

    • Coping & Stress management (crying, exercising, alcohol use).

    • Tobacco/Nicotine (include e-cigs – smell harder to detect; vasoconstriction effects).

    • Alcohol & Drugs (detailed section below).

    • Occupational health (chemical exposure, asbestos, fiberglass, insulation, nitrile gloves; repetitive motion; built-in exercise; nurses walk all day).

Substance Use & Abuse

Neurobiology & Definitions

  • Any rewarding substance → dopamine surge → desensitization → craving → withdrawal.

  • Chronic use impairs executive function & decision-making → brain disease model of addiction.

Alcohol – Categories & Risks

  • Moderate: ≤ 2 drinks/day ♂, ≤ 1 drink/day ♀ → still ↑ risk of breast/oral/esophageal CA.

  • Heavy: ≥ 15 drinks/week ♂, ≥ 8 drinks/week ♀ → HTN, CAD, stroke, liver dz, colorectal CA, mental illness, alcohol dependence + above cancers.

  • Binge: ≥ 5 drinks (♂) or ≥ 4 drinks (♀) within 2 hrs → injury, violence, poisoning, risky sex.

  • Legal intoxication: \ge 0.08 %BAC (≈ 3 drinks) → DUI.

Special Populations

  • Pregnancy: no safe amount; most drinking occurs in 1st trimester (unrecognized pregnancy); risk of Fetal Alcohol Syndrome (facial changes, cognitive/behavioral deficits). Reference photo p. 274.

  • Adolescents: developing brain already slowed by screen time; alcohol/nicotine delay maturation; one JUUL pod ≈ 20 cigarettes.

  • LGBTQ+ (sexual/gender minorities): 1.5–3× higher rates of alcohol/illicit drug use due to discrimination, weaker support.

Illicit Drugs

  • Marijuana (80 % of illicit use), cocaine, meth, opioids, heroin, hallucinogens.

  • Fentanyl contamination → overdose; harder to reverse with naloxone.

  • Xylazine ("tranq") now mixed with fentanyl.

  • Trend from prescription opioids → heroin when PDMPs limit refills.

Workplace & Legal Concerns

  • Nurses/federal employees: zero-tolerance for THC even if state-legal.

  • Post-incident drug screens after injury; positive → loss of Workers’ Comp / job.

  • Prescription stimulants (e.g., amphetamines for ADHD) are allowed if declared and non-impairing.

  • DUI or drug charge complicates NCLEX eligibility; disclose early to program director; first DUI often bars sitting for exam.

Assessment Tools & Strategies

  • AUDIT (p. 87) – detects hazardous vs harmful drinking.

  • CAGE – lifetime screening (Cut down, Annoyed, Guilty, Eye-opener).

  • Quick 4-question screen: bodily harm, relationship issues, legal trouble, work/school failure in past 12 mo → ≥ 1 “Yes” = abuse.

  • Objective:

    • \text{BAC / BAL} via blood or breath; normal = 0.

    • CIWA scale for withdrawal.

  • Table 6.6 (p. 93): know broad principle – stimulant intoxication → depressant-type withdrawal & vice-versa.

Violence & Abuse

Intimate Partner Violence (IPV)

  • Types

    • Physical (attempted/completed acts).

    • Sexual (attempted/completed acts; includes forced exposure to porn).

    • Stalking (unwanted attention causing fear: calls, texts, property damage, repeated appearance).

    • Psychological aggression (verbal/non-verbal control, emotional harm).

  • Statistics

    • 20 hotline calls/min = ~19 000 calls/day.

    • ~50 % female homicides by current/former partner.

  • Screening

    • Joint Commission mandates a tool but not specific instrument.

    • All women of child-bearing age (~14+) should be screened each encounter.

    • Use open-ended, non-judgmental questions.

    • Separate patient from partner/family for disclosure.

Elder Abuse & Neglect

  • Physical, sexual, emotional, financial abuse or neglect (food, clothing, meds, supervision).

  • Often perpetrated by family/caregivers.

  • Nurses are mandated reporters for vulnerable adults & all minors; suspicion alone is sufficient.

Human Trafficking (Modern Slavery)

  • Force, fraud, coercion to obtain labor or commercial sex.

  • Victims often depend on trafficker for housing/food; fear deportation, discrimination.

  • May be any ethnicity, US or non-US citizen.

  • Health sequelae: TBI, chronic pain, STIs, PTSD, substance abuse.

  • Build rapport; watch for inconsistent stories, serial injuries, controlling companion.

Assessment & Documentation of Abuse

  • Perform head-to-toe; photograph with institutional camera only with consent (unless incapacitated).

  • Describe objectively: size, shape, color of bruises; e.g., "5 cm × 2 cm purple ecchymosis on right upper arm" (avoid "healing bruise").

  • Maintain quotes for patient’s own words.

  • Coding signals in public:

    • "Angel Shot – neat" = escort to car.

    • "Angel Shot – with a twist" = call police.

    • Clinic urine label written in red ink may signal danger when companion present.

Practical Tips & Ethical Reminders

  • Nursing care is non-judgmental; personal opinions/religion must not influence patient rapport.

  • Use chosen name & pronouns; focus on health risks tied to anatomy.

  • It is "okay to be rude" if you feel unsafe—leave situation.

  • Build trust first; patients will reveal more when respected.

Blink Break & Self-Care (Classroom Note)

  • Instructor introduces "blink break" → look away from screen 20 sec every 20 min to prevent eye strain.

  • Encourages stretching and regulated sleep schedule despite nursing school demands.

Key Numbers & Formulas

  • Legal driving limit: 0.08\% BAC.

  • Moderate intake thresholds: \le 1 drink/day (♀), \le 2 drinks/day (♂).

  • Heavy intake thresholds: \ge 8 drinks/week (♀), \ge 15 drinks/week (♂).

  • Binge event: \ge 4 drinks in 2 h (♀), \ge 5 drinks in 2 h (♂).

  • One JUUL pod ≈ 20 cigarettes.

To-Do / Study Reminders

  • Review Table 6.6 (drug intoxication vs withdrawal opposites). One exam question promised.

  • Remember CIWA attributes and normal BAC = 0.

  • Know mandated-reporter thresholds and populations.

  • Distinguish sex (birth anatomy) vs gender identity in documentation.