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
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.
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.
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).
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).
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.
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.
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.
- 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.
- 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.