Epidemiology (ch. 9/pg.

147)
Epidemiology investigates the distribution and determinants of disease events and disease
trends or health-related states or events and trends in a population.
1. Types of epidemiology
a. Descriptive Epidemiology
i. Discusses a disease in terms of person, place, and time
ii. When using this type, health outcomes are considered in terms of what
who, where, and when.
1. What is the outcome? Who is affected? Where are they? When
do events occur?
b. Analytic Epidemiology
i. The focus on investigation of causes and associations
ii. The how/why or determinants of health events, are those factors,
exposures, characteristics, behaviors, and contexts that
determine/influence the patterns:
1. How does it occur? Why are some people affected more than
others?
2. Determinants of may be individual, relational or social,
communal, or environmental.
2. The components/factors of the Epidemiologic Triangle/Triad
a. Disease results from complex relationships among causal agents, susceptible
persons, and environmental factors; changes in one of the elements of the
triangle can influence the occurrence of disease by increasing or decreasing a
person’s risk for disease.

Component: Definition: Examples:

Agent An animate or  Infectious: bacteria, viruses, fungi, parasites
inanimate factor that  Chemical: heavy metals, toxic chemicals,
must be present or pesticides
lacking for a disease or  Physical: radiation, heat, cold, machinery
condition to develop.
Host A living species  Genetic susceptibility
(human/animal)  Immutable characteristics: age or sex
capable of being  Acquired characteristics: immunological status
infected or affected by  Lifestyle factors: diet or exercise
an agent.
Environment All that is internal or  Climate: temperature, rainfall
external to a given host  Plant and animal life: agents, reservoirs, or
or agent and that is habitats for agents
influenced and  Human population distribution: crowding, social
influences the host support
 and/or agent.  Socioeconomic factors: education, resources,
access to care
 Working condition: level of stress, noise,
satisfaction
Vector

b. Host, Agent, Environment, Vector

i. Know the role/function of each component/factor in the communicable
disease process
3. The components/factors of the Determinants of Health Model (web of causality)

4. Modes of disease transmission (airborne/droplet, contact, ingestion, etc.)

5. Stages of Natural History of disease model
6. Incidence vs. Prevalence; Proportion vs. Probability; Rate vs. Ratio
a. Know the definitions of these concepts
b. Know the differences between the concepts
 c. Know how to calculate these concepts
d. Know how these concepts are used to describe/measure/evaluate health
outcomes
7. Information/data sources
a. Surveillance data, survey data, vital statistics (birth/death records), etc.
8. Types of Surveillance (Active, Passive)
9. Levels of Prevention (Primary, secondary, tertiary, primordial)
10. Rates inform about risk

Disasters (ch. 14/pg. 236)

1. Definition - devastation that requires assistance for relief/recovery
2. Disaster Management Stages pg. 239
a. Prevention: all hazards mitigation (prevention) is an emergency management
term for reducing risks to people and property from natural hazards before they
occur.
i. Other prevention activities include:
1. Detection efforts (weather, weapons)
2. Surveillance/inspections (public health environments,
transportation environments, food sources)
3. Immunizations
ii. Nurse Role:
1. Advocate for communities
a. Resources, services
b. Assess for, identify, & report potential hazards to physical,
psychological, or sociological health/safety
2. Caregiver
a. Mass prophylaxis or immunization efforts
b. Assist in containment when total prevention not possible
b. Preparedness:
i. A disaster preparedness plan must be both realistic and simple because:
1. No plan will ever exactly fit the disaster as it occurs
2. All plans must be able to be implemented no matter what key
members of the disaster team are there at the time
ii. Communities use education, team planning, mock disaster events, and
clear assignment of responsibility to health care professionals in the
community to:
1. Reduce community vulnerability
2. Develop disaster response plans
3. Provide training before any hazardous event
iii. Personal preparedness: personal checklist and emergency supplies kit
 iv. Professional preparedness: nurse understands workplace/community
disaster plans and participates in disaster drills and community mock
disasters
v. Community preparedness: Office of Emergency Management (OEM) and
nurse reviews disaster history of the community
vi. Mass casualty drills or mock disasters
vii. Nurse role: Help initiate or update the agency’s disaster plan, provide
educational programs and materials regarding disasters specific to the
area, organize disaster drills, provide an updated record of vulnerable
populations within the community, Review individual strategies
c. Response: Levels of disaster and agency involvement
i. Levels determined not by number of casualties, but by the amount of
resources needed
ii. Three ways to classify a disaster (ARC)
1. Disaster type – cause
2. Disaster level – amount of response/assistance needed
3. Disaster scope – magnitude of impact
iii. The NRF
iv. 15 emergency support functions (ESFs)
1. National disaster medical system (NDMS)
a. Disaster medical assistance teams (DMATs)
v. Nurse role: The role of the nurse in disaster response depends on nurse’s
experience, professional role in a community disaster plan, specialty
training, and special interest
1. Shelter management: Nurses make ideal shelter managers and
team members because they are comfortable with dealing with
aggregate health promotion, disease prevention, and emotional
support
d. Recovery: Recovery occurs as all involved agencies pull together to restore the
economic and civic life of the community. Often the most difficult stage of
disaster/disaster management.
i. Nurse role:
1. Teach proper hygiene and make sure immunization records are
current
2. Make referrals to mental health professionals
3. Be alert for environmental hazards
4. Assess dangers of live or dead animals
5. Case finding and referral

Politics/Legislation (ch. 3/pg. 33)

1. Vaccination requirements
2. Structure of the U.S. Healthcare system
a. Two components pg. 39
i. Private (personal) health care: Managed care is a system in which care is
delivered by a specific network of providers that agree to comply with
the care approaches established through a case-management approach.
ii. Public health care: A system mandated through laws that are developed
at the national, state, or local level.
b. Levels (which level governs which services?) pg. 39
i. Federal: U.S. department of health and human services, department of
justice, department of defense, department of agriculture, department of
commerce, department of labor.
ii. State: State health departments
1. Disaster preparedness and response
2. Health care financing and administration for programs (ex.,
Medicaid)
3. Establishing health codes
4. Licensing facilities and personnel
5. Direct assistance to local health departments
iii. Local: direct responsibility to citizens in its community or jurisdiction
1. Services vary depending on:
a. State and local health codes that must be followed
b. Needs of the community
c. Available funding and other resources
c. Challenges (Multiple payers, multiple providers, multiple settings, multiple
influencers)
d. Three priority concerns pg. 38
i. Access: Lack of access to healthcare due to uninsurance or
underinsurance.
ii. Cost: this cost is on the healthcare side not the patient side.
iii. Quality: the quality of care received by the patient.
e. Medicare vs. Medicaid pg. 138
i. Medicare: provides hospital insurance and medical insurance to persons
aged 65 year and older, to permanently disabled persons, and to person
with end-stages renal disease. It has two parts:
1. Part A (hospital insurance): covers hospital care, home care, and
skilled nursing care (limited).
2. Part B (noninstitutional care insurance): covers ‘medically
necessary’ services and physiotherapy.
 ii. Medicaid: provides financial assistance to states and counties to pay for
medical services for poor older adults, the blind, the disabled, and
families with dependent children.

U.S. Health and Public Health Systems (ch. 3/pg. 33)

1. Structure (see above)
2. Factors/Trends influencing the system (slides)

Demographic  Population growth of the world

o Increased fertility in low resource/income countries (developing
nations)
o Increased longevity of adults in high & middle resource/income
countries (developed and developing nations)
 Aging Baby Boomer generation
o Growing size of older adult population (more details in text Ch. 8)
o Decreasing size of younger adult population (baby bust)
 Change in largest minority group
o Shift from African Americans to Latin American (Hispanic)
o Growing foreign-born population (Latin America, Asia, others)
 Changing composition of the U.S. household
o Increased # of single-parent households
o Increased # of same-sex parented households
 Declining mortality for both genders in all age groups
o Decreased infant mortality
o Children and adults living longer
Social and  Changing lifestyles
Economic o More people engaging in self-care activities to stay healthy (ex.
fitness, complementary medicine)
 Growing appreciation of the quality of life
o Good health viewed as key to living a quality life → good health
costs money → financial success important → trend toward
changing household incomes (increases in # of higher income
households)
 Changing composition of families and living patterns
o Decreases in the number of children (in families and among
millennials)
o Changes in marriage (same sex), divorce (divided households),
blended families (mixed households)
 Changing household incomes
o Average per-person income is increasing
o Widening gap between high-income earning households and low-
income earning households
  Revised definition of quality health care
o Has changed over time
o Has changed by perspective (IOM, AHRQ, Providers, Patients,
Insurers/Payers, etc. see pg 279)
 Economic downturn of 2008
o Impacts on financial resources of families, business/industry, etc.
persist → impacts on ability to access health care
 Affordable Care Act
o Attempts to increase access to health care to more people
Health  Not enough primary care providers
Workforce o Paucity in rural & inner-city areas
o Providers (medical & nursing) more interested in specialization
than primary care (generalist care)
o Advanced practice nursing (APN) specialties important to having
enough providers
 Move to contain costs and move to community-based care
o Fluctuations in Hospital care ↔ Community-based care
 Current nursing shortage
o For hospital care providers
o For community-based & public health care providers
o For primary care providers
 Need to increase the diversity of the nursing workforce to help decrease
health disparities
o Nurses from different racial, ethnic, and language backgrounds
Technological  Positive effects
o Improvement in delivery of health care services and in outcomes
o Reduction in costs
o Increased convenience
 Negative effects
o Increase in costs (ex., expensive, high-tech equipment)
o Legal liability
o Potential for decreased privacy
o Too much reliance on machines
 Digital divide
o Millennials and younger generations very comfortable with
technology
o Technology disparities (generational, haves & have nots)
 Electronic medical records
o Expensive to set up, but has potential to increase portability of
patient records
o Allows clinicians to have access to reminders & clinical guidelines
at the point of care
 o 24-hour access to information
o Increased inter-provider/inter-professional communication

Health Initiatives
1. Healthy People 2030 (vision, mission) https://health.gov/healthypeople/about/healthy-
people-2030-framework
2. U.N. Sustainability goals (https://sdgs.un.org/goals)
3. Which of the 17 UN sustainability goals aligns with HP2030 vision/mission?

Community Assessment (ch. 12/pg. 203)

1. The importance/purposes of needs assessments, data collection, problem
identifications, inventorying of resources
a. Assessments pg. 211: Helps the nurse in community health to understand
individual, family, and group problems and to know what community strengths
and resources are available to help the nurse solve the client’s problems.
b. Data collection pg. 211: To get usable information about the community and its
health.
c. Problem identifications pg. 211: Important first step to planning to prioritize
during the planning phase and identify interventions.
d. Inventorying of resources:
2. The importance/purposes of community partnerships or involvement pg. 209
a. This is necessary because when there is community partnership, lay community
members have a vested interest in the success of effort to improve the health of
their community.

Program Management (ch. 16/pg. 265)

1. Steps involved (know all) pg. 266
2. Aspects of evaluation (Relevance, Adequacy, Effectiveness, Impact, Sustainability) pg.
273
a. Relevance: the need for the program
i. An important component of the initial planning phase. As money,
providers, facilities, and supplies for delivering health care services are
more closely monitored, the needs assessment done by the nurse will
determine whether the program is needed.
b. Adequacy: the program addresses the extent of the need
i. Looks at the extent to which the program addresses the entire problem
defined in the needs assessment. The magnitude of the problem is
determined by vital statistics, incidence, prevalence, and expert opinion.
 c. Effectiveness: The ability to meet the program objectives and results of program
efforts
i. May help the nurse evaluator determine both client and provider
satisfaction with the program activities, as well as whether the program
met its stated objectives.
d. Impact: Long term changes in the client population
i. Long term effects such as changes in morbidity and mortality must be
investigated.
e. Sustainability: Enough resources (usually money) to continue the program
i. A program can be continued if there are resources for the program.
3. Aspects of success (available, accessible, acceptable to the target community) pg. 268
a. Available: Available resources must be identified before implementing a health
program and include:
i. Personnel, facilities, equipment, and financing; without one of these
resources the program is likely to inadequate to the meet the needs of
the client population.
b. Accessible:
c. Acceptable:

Health Conditions
1. Know leading health concerns (categories) and associated risk factors
a. Accidents & injuries: result from unintentional or intentional acts that lead to
personal harm.
i. Risk factors: cognitive impairment/immaturity/developmental disability,
mental illness, hazardous environmental conditions, socio-cultural
factors, age, race, gender
ii. Accidents & injuries are leading causes of preventable disease, disability,
& death among children
b. Infectious (communicable) conditions: spread by direct contact with infectious
agents: bacteria, viruses, fungi, and protozoa.
i. Risk factors: children, elderly, immunosuppressed, IV drug users, HCWs,
unvaccinated persons
c. Chronic (non-communicable) conditions: include chronic conditions
i. Risk factors: children, adolescents, adult men/women, homeless, persons
with disabilities
2. Know leading health concerns and types of populations most impacted
a. Infants/Children, Adolescents
b. Families/people with limited resources and power (ex., incarcerated, migrant
farm workers, other vulnerable)
c. Health care workers
3. Know assessment guidelines (risk factors, defining characteristics), screening, testing,
treatment, health risks for the following:
a. Tuberculosis: among the top causes of communicable disease deaths worldwide
i. Etiology: mycobacterium tuberculosis
ii. Risk factors: HIV+, immunosuppressed for other reasons, contacts to TB,
old healed TB, foreign body, incarcerated, homeless, chemically
dependent, congregate living, elderly, HCWs, MFWs, medically
underserved
iii. Symptoms: cough > 3 weeks, weight loss, night sweats, fatigue
iv. Screening: skin testing with purified protein derivative (PPD)
v. Testing: chest x-ray for those with a positive skin reaction and pulmonary
symptoms
vi. Treatment: The emergence of multidrug-resistant TB has prompted the
use of directly observed therapy (DOT) in the U.S. and other countries to
ensure adherence with drug treatment regimens
1. Isoniazid (INH)
2. Rifampin
3. Pyrazinamide
vii. Health risks:
b. Hepatitis A: short term inflammation of the liver.
i. Etiology: virus (HAV), spread through food/water contaminated by stool
ii. Risk factors: International travelers (Asia, South/Central America), IV drug
users, Long-term care residents, Health care workers, Food service
workers, Sewage workers, Anal-oral sex participants
iii. Symptoms: Flu-like symptoms, jaundice, low-grade fever
iv. Screening: History of illness/ROS and physical exam/ROS
v. Testing: hepatitis serology tests
vi. Treatment: rest, avoid exacerbating symptoms by avoiding fatty foods,
acetaminophen, and alcohol
vii. Prevention:
1. Wash hands after using the bathroom
2. Wash hands after contact with another person’s blood/body
fluids/stools
3. Avoid contaminated foods/water
4. Avoid anal-oral sex activities with infected persons
c. Hepatitis B: acute or chronic inflammation of the liver.
i. Etiology: virus (HBV), spread through blood, semen, vaginal, and other
body fluids
ii. Risk factors: persons born in regions with high infection rates, persons
with multiple sex partners, MSM, persons receiving hemodialysis, and
persons infected with HIV.
 iii. Symptoms: few or none
1. Early: low grade fever, fatigue, jaundice, muscle/joint aches
2. 6 months after infection and chronic disease has different
symptoms
iv. Screening: History of illness/ROS and physical exam/ROS
v. Testing: Blood tests- Albumin level, LFT, Hep B antigen/antibody tests
vi. Treatment: best rest, fluids, nutritious foods, liver transplant in severe
cases leading to liver failure, antiviral occasionally
vii. Prevention:
1. Vaccination
2. Avoid sexual contact with infected person
3. Avoid sharing personal items (i.e., toothbrushes/razors) with
infected persons
4. Avoid sharing needles/drug paraphernalia
5. Avoid contact with infected body fluids
d. Hepatitis C: acute or chronic inflammation of the liver.
i. Etiology: virus (HCV)
ii. Risk factors: persons on long term dialysis, who work with blood
(healthcare), who have unprotected sex, IV drug users, and who receive
tattoos and acupuncture in poorly monitored facilities
iii. Symptoms: usually none
1. Possible: jaundice, low-grade fever, flu-like symptoms, abdominal
pain, dark colored urine, pale stools, fatigue, ↓ appetite, muscle
aches
iv. Screening: History of illness/ROS and physical exam/ROS
v. Testing: Blood tests- Hep C antibodies, LFT, albumin levels
vi. Treatment: Sustained viral response (SVR) is possible
1. Medications – direct acting agents (DAA), Ex., Harvoni for chronic
HCV
2. Note: HCV can clear from some people’s bodies without
intervention
vii. Prevention:
1. Avoid contact with blood or blood products
2. Avoid IV drug use/needle sharing
3. Use caution when getting tattoos or piercings
4. Avoid having multiple sex partners
4. Know vaccine-preventable conditions (focus on conditions from lecture slides)

Population/Culture-related Content (ch. 5/pg. 65)

 1. Cultural Imposition pg. 39: Involved the belief in one’s own superiority, or
ethnocentrism, and the act of imposing one’s values on others.
a. Nurses impose their values on clients when they forcefully promote western
medical traditions while ignoring the clients’ value of non-western treatments
such as acupuncture, herbal therapy, or spiritual remedies.
2. Ethnocentrism pg. 39: A type of cultural prejudice at the population level, the belief that
one’s own group determines the standards for behavior by which all other groups are to
be judged.
a. Ethnocentric nurses are unfamiliar and uncomfortable with anything that is
different from their culture. Their inability to accept worldviews often leads
them to devalue the experience of others, judge them to be inferior and treat
people who are different with suspicion or hostility.
3. Racism pg. 39: A form of prejudice and refers to the belief that person who are born
into a particular group are inferior. Because of their race, individuals may be denied
opportunities that are available to people of other races. Racism can be one of the three
forms:
a. Individual: because of the characteristics of the group of which the person is a
member, such as skin color, hair texture, or facial features.
b. Institutional: such as discriminatory policies, priorities, and resource allocation
pertaining to certain groups.
c. Cultural: in which a culture is viewed in a derogatory or stereotypical ways
because of for example a group dresses or the language used.
4. Stereotyping pg. 39: attributing certain beliefs and behaviors about a group to an
individual without giving adequate attention to individual differences.
a. Ex: “All Asian people are hardworking” or “All Chinese people are good at math.”
5. Disparity
6. Cultural perspectives/views (ex., etic, emic)
7. Vulnerable populations (children, disabled, incarcerated, pregnant women, people with
limited resources, migrant farm workers)
a. At risk for poor health outcomes
8. At risk populations/groups (often target for interventions/support)
9. Use of communication modalities that respect/acknowledge cultural and linguistic group
differences
a. Therapeutic
b. Interpreters

CHN History (ch. 2/pg. 15)

1. Elizabethan Poor Law (relationship to Medicaid)
a. Systems of care for the sick, poor, aged, mentally ill, and dependents based on
this law.
 b. Early county or township government was responsible for the care of all
dependent residents but provided almshouse charity carefully, economically,
and only for residents. Travels and people who lived elsewhere were returned to
their native countries for care.
2. Prominent figures (ex., Florence Nightingale, Bessie Hawes, Jessie Sleet/Scales, Lina
Rogers)
3. School nursing: Issues of concern in early 20th century pg. 21
a. Limited funding during this time was the major obstacle to extending nursing
services in the community.

General Nursing Knowledge You Should Have Acquired to Date and Can Apply to
CHN-Related Scenarios
1. Nursing Diagnoses (statements, defining characteristics, relevance to patients and how
to select those most appropriate to patients’ needs)
2. Therapeutic communication (what to say and what not to say to patients)
