Respond to two of your colleagues who were assigned a different patient than you. Critique your colleague’s targeted questions, and explain how the patient might interpret these questions. Explain whether any of the questions would apply to your patient, and why.

Peer 1

Ariana Neff

 Shawn Billings, a 28-year-old African American patient comes into the clinic today. He has been deemed a “frequent flyer” by the staff at the clinic and was at the clinic last week and 4 days ago with a migraine, given a shot of Toradol and Ativan and sent home. He is here today again for an extreme headache. He is very agitated today. He is here with his father and is worried that he will not get any medication.

Post an explanation of the specific socioeconomic, spiritual, lifestyle, and other cultural factors associated with the patient you were assigned.

From a medical perspective, those who attend the emergency room (ED) more than ten times a year are considered frequent flyers. Their complex medical and social conditions, which include greater rates of disability, mental illness, substance misuse, and homelessness, are more likely to affect men, and they are more likely to be homeless. They are less likely to need hospital admission, making the cost to the health care system lower (EMRA, 2019).

An incident of moderate to severe throbbing and pulsating pain on one side of the head occurs repeatedly with migraine headaches. Attacks go untreated for four to 72 hours. The pain from ordinary physical activity, movement, or even coughing or sneezing can exacerbate other typical symptoms such as heightened sensitivity to light, noise, and scents, nausea, and vomiting. Mornings are when migraines most usually strike, especially right after awakening. Other people experience migraines at regular intervals, such as the day before their period or the weekend after a challenging work week. Although many people experience weakness or exhaustion after a migraine, they are typically symptom-free in between attacks (NIH, 2023).

Treatment for migraines aims to reduce symptoms and stop further attacks. A cool cloth or an ice pack can be applied to the forehead to relieve symptoms. Other quick remedies include napping or resting with the eyes closed in a quiet, darkened area (NIH, 2023).  

There are two types of drug therapy for migraines: acute and preventative. To treat pain and regain function, acute or “abortive” drugs are used as soon as symptoms appear. The goal of preventive treatment is to lessen the severity of upcoming attacks or prevent them from occurring altogether (NIH, 2023).

Any of the following medicines may be used as acute migraine treatment: Serotonin levels in the brain are raised by triptan medications. Blood vessels tighten as a result of serotonin, which also lowers the pain threshold. The preferred migraine medication, triptans, reduces moderate to severe migraine discomfort. Drugs made from ergot bind to serotonin receptors on nerve cells to lessen the flow of pain signals along nerve fibers. They work best when migraines are still in the early stages.  Less severe migraine headaches can be treated with over-the-counter or non-prescription analgesics such as acetaminophen, aspirin, or ibuprofen. Combination analgesics combine medications, such as caffeine and acetaminophen, to treat migraines that may be resistant to simple analgesics. NSAIDs, which are non-steroidal anti-inflammatory medicines, can alleviate pain.  Prescription nausea medications can reduce nausea brought on by different forms of headache. Narcotics are momentarily prescribed to treat pain. Chronic headaches shouldn’t be treated with these medications (NIH, 2023).

Acetaminophen and nonsteroidal anti-inflammatory drugs are first-line treatments for mild to moderate migraines, whereas triptans are first-line treatments for moderate to severe migraines.  Toradol is a medication approved by FDA (Food and Drug Administration) to treat short-term, moderately severe pain. It is a member of the class of pharmaceuticals known as nonsteroidal anti-inflammatory drugs (NSAIDs). Additionally, it is also utilized off-label to relieve migraine pain (AAFP, 2018).

Ketorolac is neither a narcotic nor a habit-forming substance. As opposed to opioids, it won’t result in physical or mental reliance. Yet, when combined with a narcotic, ketorolac can occasionally offer greater pain relief than either drug by itself. The negative effects of ketorolac might be extremely harmful. With the dosage of ketorolac and the duration of treatment, the probability of experiencing a major adverse effect rises. As a result, using ketorolac for more than five days is not advised (MayoClinic.org, 2023).

At the time of headaches, everyone with migraine needs excellent therapy. Some sufferers with severe, recurrent migraines require preventative medicine. In general, prophylaxis should be considered if migraines happen at least once a week or if they are less common but incapacitating. For people who take symptomatic headache medication more than three times per week, preventive medications are also advised. A migraine sufferer should also take one or more preventive drugs for two to three months to evaluate the effectiveness of the treatment unless unbearable side effects arise (NIH, 2023).

Several migraine prevention medications were previously promoted for illnesses other than migraine.  In addition to migraine, anticonvulsants may be beneficial for people with other forms of headaches. These medications, despite being initially designed to treat epilepsy, raise levels of specific neurotransmitters while reducing pain signals.  Beta-blockers are prescribed to lower blood pressure and are frequently successful in treating migraines.  Calcium channel blockers serve to stabilize blood vessel walls and are used to treat excessive blood pressure. These medications appear to function by halting the blood vessels’ ability to either widen or restrict, which has an impact on blood flow to the brain. Antidepressants affect several brain chemicals; their ability to treat migraines is not directly correlated with how they affect mood. Antidepressants could be beneficial. As antidepressants stimulate serotonin production and may also impact levels of other neurotransmitters, such as norepinephrine and dopamine, they may be beneficial for people with different types of headaches (NIH, 2023).

Riboflavin (vitamin B2), magnesium, coenzyme Q10, and butterbur are all natural migraine remedies (medicinal plants). Biofeedback and relaxation training are two non-drug treatments for migraines that assist sufferers in managing or controlling the onset of pain and the body’s stress reaction. Exercise, avoiding foods and drinks that cause headaches, eating regularly scheduled meals with enough water, quitting some medications, and having a regular sleep pattern is all lifestyle modifications that lessen or prevent migraine attacks in some people (NIH, 2023).

Explain the issues that you would need to be sensitive to when interacting with the patient, and why. What strategies can you as a nurse employ to be sensitive to different cultural factors while gathering pertinent information?

In order to provide patient-centered care, communication skills such as focused active listening, not interrupting the patient, and asking open-ended questions are necessary. Patient-centered communication emphasizes the need to comprehend the patient’s perspective on the condition and demonstrate empathy (Hashim, 2017).

The patient in this case study may be known as a frequent flyer to the clinic, partly because the clinic assisted him with only temporary relief and did not provide a treatment that would be required for a possible long-term or ongoing issue. Perhaps a referral to a neurologist at this point may assist the patient in obtaining more adequate treatment for the issue involved.

Investigating the patient’s thoughts, feelings, experiences, and concerns about the effects of the illness as well as what the patient anticipates from the doctor will help you better understand the patient’s point of view. Empathy can be demonstrated by naming the feeling, expressing respect, understanding, and support, as well as through learning about the patient’s sickness experience and feelings (Hashim, 2017)

By allowing patients to weigh the benefits and drawbacks of many treatment alternatives, including no treatment, shared decision-making empowers patients. Little doses of medical knowledge should be given to the patient repeatedly utilizing the “ask-tell-ask” method rather than bombarding them with it (Hashim, 2017).

What questions would you ask, and how would you frame them to be sensitive to the patient’s background, lifestyle, and culture? Provide at least five targeted questions you would ask the patient to build his or her health history and assess his or her health risks.

1. “Don’t assume. Ask the patient about background, practices, religion, and culture to avoid stereotyping (American Psychiatric Association Publishing, 2020), ”
2. “Reassure by words and actions that you are interested in understanding the patient and helping to co-construct a plan to fit his or her needs. State upfront that this is a collaborative process and that you welcome input on the process (communicating openly with each other) and the treatment plan (American Psychiatric Association Publishing, 2020).”
3. “Discuss patient-centered care to determine whether this is understood or if this is an unfamiliar practice. Get patient input about collaborating in health care decisions. For patients who are accustomed to the doctor being the one making all the decisions, consider initiating a request for decisions, even small ones, to reinforce to them that you want to know their preferences and help them become comfortable with making health care decisions and communicating wants and needs )American Psychiatric Association Publishing, 2020).”
4. “Inquire about what the patient feels would be helpful. Are there cultural practices or herbal remedies that they have already tried—and what was the result? Are there religious, cultural, or individual convictions that affect the choice of treatment (American Psychiatric Association Publishing, 2020)?”
5. “Clarify the patient’s preference for family involvement and, depending on the age and competence of the patient, what information will be communicated to the family American Psychiatric Association Publishing, 2020).”

References

American Academy of Family Physicians (AAFP), (2018). Acute Migraine Headache: Treatment Strategies. Retrieved

 From.

https://www.aafp.org/pubs/afp/issues/2018/0215/p243.htmlLinks to an external site.

American Psychiatric Association Publishing, (2020). Practicing Cultural Competence and

Cultural Humility in the Care of Diverse Patients.  Retrieved From.

https://focus.psychiatryonline.org/doi/10.1176/appi.focus.20190041Links to an external site.

Emergency Medicine Resident Association (EMRA), (2019).  Emergency Medicine Advocacy

Handbook.  Retrieved From.

https://www.emra.org/books/advocacy-handbook/frequent-fliers/Links to an external site.

Hashim M. J. (2017). Patient-Centered Communication: Basic Skills. American family

physician, 95(1), 29–34.

https://www.aafp.org/pubs/afp/issues/2017/0101/p29.htmlLinks to an external site.

MayoClinic.org, (2023). Drugs and Supplements. Ketorolac (Oral Route, Injection Route). Retrieved From.

https://www.mayoclinic.org/drugs-supplements/ketorolac-oral-route-injection-route/proper-use/DRG-20066882?p=1Links to an external site.

National Institute of Neurological Disorders and Stroke (NIH), (2023).  Migraine. Retrieved

From.

https://www.ninds.nih.gov/health-information/disorders/migraineLinks to an external site.

Peer 2 

Regina Deen

Ball et al. (2019) state that a person’s age, race, ethnicity, and socioeconomic status may influence how they seek medical care. These factors may also affect the way that clinicians provide care. Behaviors, ideas, and perceptions among various ethnicities are often passed down from generation to generation (Young & Guo, 2020). However, every individual who identifies with a particular race may not follow the same attributes as others in their race. For this reason, a healthcare provider must be thorough when obtaining a health history to ensure that it is accurate and communicates a plan of care that is culturally sensitive (Young & Guo, 2020). 

      In the case study chosen, the patient is a 28-year-old African American male who is deemed a “frequent flyer” because of how often he returns to the clinic complaining of migraines and severe headaches. Frequent flyer patients are often categorized as heavy-cost patients because they can account for up to 80% of healthcare costs (Brodeur et al., 2020). Valdez (2021) states that labeling a patient, family, or community can be harmful because labels can lead to biased care, stereotypes, and adverse outcomes. Patients labeled as frequent flyers may be misdiagnosed, experience delays in care, and have unresolved healthcare needs (Valdez, 2021). 

      According to Eley et al. (2019), African American men are less likely to seek treatment or preventative health care services than other groups. It is felt that this is because masculinity and manhood are ingrained into the male culture, requiring them to personify strength and dominance and to avoid shows of emotion that may make them look weak (Eley et al., 2019). These behaviors may cause men not to seek health care, ignore symptoms of illness, have poor medication compliance, and be unwilling to discuss health concerns in order to maintain control of their own health (Eley et al., 2019). 

      African Americans are sometimes perceived as pain-seeking individuals (Dowell et al., 2022). A younger black male may be categorized as a delinquent, especially if he shows up frequently at a clinic, agitated and complaining of pain. Ball et al. (2019) state that every person is characterized by their social class, race, age, and gender. If healthcare providers are not careful, they can form biased opinions, which may affect how they communicate and treat individuals of different races and ethnicities (Ball et al., 2019).

      Charleston and Burke (2018) discuss racial disparities among African Americans who complain of migraines. These authors state that African Americans have more severe and frequent migraines than non-Hispanic whites. These migraines are more likely to become chronic, causing depression and a decreased quality of life. Healthcare providers must be well-informed of different healthcare perceptions among cultures and should also be mindful of their own perceptions (Young & Guo, 2020). Charleston and Burke (2018) state that African Americans are more likely to be misdiagnosed with migraines. They are also prescribed less acute migraine attack medications, even though these patients have a higher migraine burden (Charleston & Burke, 2018).

Sensitivity During Interactions

      The patient in the scenario arrives at the clinic agitated. It states that the last time he was at the clinic complaining of a migraine, he was given a shot of Toradol and Ativan and sent home. Ativan is not typically given for a migraine, so this information suggests the patient was also anxious or agitated at the last visit. The scenario states that the patient brought his father with him to this appointment, and he was afraid that he would not get any medication. The healthcare provider should not assume that the patient is agitated because he is exerting dominance or that this behavior is his normal temperament. The clinician should ask questions to understand what the patient is feeling. The healthcare provider should assess if the patient feels he has been dismissed during previous appointments or if he felt mistreated. Huang et al. (2020) discuss research that states that many patients who are frequent flyers often feel powerless, fear, and frustration because they feel like they are deteriorating or are unable to do their normal daily activities, making them feel out of control.

      A healthcare provider should never assume that a patient is being dishonest about their pain. Instead, they should seek to understand the pain and what may be causing the individual to keep returning to the clinic in pain. Brodeur et al. (2020) state that frequent flyers who seek ongoing or proper care often have difficulties, such as needing to call and make doctor appointments during work hours, or even missing work to go to the appointments. The healthcare provider should find out if there are any barriers that will interfere with the patient receiving a proper workup for his headaches.

Targeted Questions:

Can you tell me about your personal and family history? (High blood pressure, heart disease, allergies, family history of migraines?

Can you tell me about your headaches?

When did your symptoms begin?

Have you noticed anything that may cause the headache to begin? (Anything that you’re doing, eating or drinking, or the type of environment that you are in when they start?)

Are there any other symptoms that occur with the headache?

Have you found anything that relieves your pain?

How are your headaches affecting your daily life?

      The healthcare provider should assess the patient’s symptoms to ensure he is being treated properly for migraines, and not another underlying condition. Treatment options should be discussed with the patient, setting goals and making a realistic care plan for the patient. A follow-up appointment should be arranged with the patient to discuss if the treatment plan is working.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An Interprofessional Approach (9th ed.). Elsevier Mosby.

Brodeur, M., Margo-Dermer, E., Chouinard, M., & Hudon, C. (2020). Experience of being a frequent user of primary care and emergency department services: A qualitative systematic review and thematic synthesis. BMJ Open, 10(9), e033351. https://doi.org/10.1136/bmjopen-2019-033351

Charleston, L., & Burke, J. F. (2018). Do racial/ethnic disparities exist in recommended migraine treatments in US ambulatory care? Cephalalgia, 38(5), 876–882. https://doi.org/10.1177/0333102417716933

Dowell, D., Ragan, K. R., Jones, C. M., Baldwin, G. T., & Chou, R. (2022). CDC clinical practice guideline for prescribing opioids for pain. Morbidity and Mortality Weekly Report, 71(3), 1–95. https://doi.org/10.15585/mmwr.rr7103a1

Eley, N. T., Namey, E., McKenna, K. E., Johnson, A. J., & Guest, G. (2019). Beyond the individual: Social and cultural influences on the health-seeking behaviors of african american men. American Journal of Men’s Health, 13(1), 155798831982995. https://doi.org/10.1177/1557988319829953

Huang, M., Van Der Borght, C., Leithaus, M., Flamaing, J., & Goderis, G. (2020). Patients’ perceptions of frequent hospital admissions: A qualitative interview study with older people above 65 years of age. BMC Geriatrics, 20(1). https://doi.org/10.1186/s12877-020-01748-9

Valdez, A. M. (2021). Words matter: Labelling, bias and stigma in nursing. Journal of Advanced Nursing, 77(11), 33–37. https://doi.org/10.1111/jan.14967

Young, S., & Guo, K. L. (2020). Cultural diversity training. The Health Care Manager, 39(2), 100–108. https://doi.org/10.1097/hcm.0000000000000294

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