Peer Reviewed Journals Nursing Diagnosis Obesity and Poverty Correlation

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"I Live WITH SLEEP Deprivation every 24-hour interval; information technology makes me moody, aroused, and unable to concentrate. It'southward a miserable way to live!" said Mr. H, 35 and single, sitting across from me in a local shelter. Homeless for eighteen months, he was wearing ragged pants and a hooded sweatshirt, which he'd picked up at the Salvation Army. Although his dress looked clean, his strong body scent permeated the air. Speaking in a soft monotone and avoiding eye contact, he clenched his fists and continued, "We're all different. I detest when people stereotype us as lazy, crazy, evil, or stupid. I have 3 years of college."

Nurses working in any public, private, or veterans' hospital are responsible for providing homeless persons realistic plans for follow-upward and advisable referrals to community agencies on discharge. Nurses working in jails and prisons should develop discharge plans that include referrals for housing and healthcare earlier inmate release. The Joint Committee mandates all patients receive safe discharge from healthcare facilities.^ane

This article explores the health problems of homeless people like Mr. H, how these health problems tin can impact other people, and how nurses can best intendance for these vulnerable patients.

Sobering facts

Homelessness kills! This multidimensional problem harms the wellness of both homeless people and the general public. The many infectious disease that homeless people contract may atomic number 82 to outbreaks that later become serious public health hazards. Prove suggests appropriate public health interventions tin prevent and control the spread of affliction.ⁱⁱ

In 2011, about 636,000 people, more men than women, were homeless in the United States, a subtract of 1% from 2009.ⁱⁱⁱ A study the same yr reported ane in 50 children was without a home.⁴ Over the last decade, the number of homeless families, many headed past single mothers in their 20s, has increased significantly. Many of these women have left a domestic situation because of physical and/or mental abuse.^{5 , vi} One study found about 25% of the gay and lesbian population and 15% of bisexuals reported homelessness compared with 3% of the heterosexual population.⁷

The prevalence of physical illnesses, including infectious diseases, amid homeless persons ranges from 33% to 55%. Their average life expectancy is 44 years compared with 78 years for the general U.South. population.^one Their historic period-adjusted bloodshed is three to 6 times higher than for people with housing.^one Homelessness affects single people, families, and children in both urban and rural areas, although in farm communities, family unit and friends are more probable to offering temporary housing and other assistance.⁵

In urban renewal efforts to create more attractive neighborhoods, many unmarried room occupancy (SRO) hotels were eliminated, which increased the number of homeless people. Deinstitutionalization of the chronically mentally ill from public psychiatric hospitals and the high unemployment rate both exacerbated the problem.⁵ For more than insight into the root causes of homelessness, come across Understanding two types of poverty.

Concurrent problems

The persistently homeless live in constant chaos, confusion, and fright. Trauma from head injuries, gunshot wounds, stab wounds, lacerations, and/or fractures is a significant cause of death and disability.⁵ Hypothermia in the winter and dehydration in the summertime are of particular business organization.

Homeless people too feel higher rates of chronic affliction, comorbidities, and physical limitations than the general population. For instance, many vision problems aren't addressed.^eight Nigh homeless people have at least one chronic illness and untreated health problems to which they've adjusted. Many have adjusted to the functional disabilities of their chronic health problems.^{1 , 5 , viii} (Run into Nothing in on chronic atmospheric condition.) For example, Ms. T, a middle-aged homeless woman visiting the shelter, spoke of long-term untreated digestive problems that she "simply lives with."

From 20% to 25% of homeless people have mental wellness illnesses.^ix Some deny mental disease and refuse treatment.

Substance corruption is a mutual comorbidity.¹¹ 80-four percent of homeless men and 54% of homeless women have alcohol use disorders compared with 8% of the full general population.^{one , 10} Although 13% of the homeless are employed, physical and mental illnesses hinder the ability of near homeless people to earn enough to meet daily needs.^{6 , vii}

Special populations, special concerns

Among the homeless, veterans, old convicts, and minority groups are disproportionately represented. Homeless meaning women have high rates of sexually transmitted infections (STIs) and drug addiction and are at run a risk for complex health problems. Their infants are more than likely to be born prematurely and have lower Apgar scores.⁵

Children younger than historic period 5 are at high risk for developmental delays and impaired brain development. Virtually homeless children take more concrete, mental health, and learning issues than poor children who are housed.⁵

Homeless teens may be runaways attempting to escape physically or sexually abusive home environments. They may commutation sex for nutrient, habiliment, and shelter, which increases their take chances for HIV/AIDS, STIs, and unintended pregnancy.⁵

Homeless youth come from all socioeconomic levels of gild, non only from poor households, and are more likely to alive outdoors than older homeless people. Many feel physical or sexual victimization after leaving their homes.¹² Some are transitioning from foster care.^three Depression and suicidal ideation are common. These youth demand reunification with families or supportive residential housing.¹²

Unique characteristics

All homeless people are vulnerable physically, socially, psychologically, and spiritually; they experience higher rates of violence, homicide, and suicide than the housed. Children, women, and older adults are the most defenseless.^{5 , 10 , xiii}

Many habits of homeless people, such equally panhandling, exceptional bathing, and obtaining food from dumpsters, disharmonize with cultural norms. Oft enduring conditions that would incapacitate others, homeless people may derive a sense of achievement from their survival skills they didn't feel in the mainstream world.

Those who value the common theme of self-survival have learned to rely on only themselves and their peers. Some lead a nomadic life and spend a big function of each day finding food and shelter with little thought or planning for the hereafter.

Although detached from the broader community, they honor relationships with each other and tend to share resources among themselves. They may fear losing their street skills if they assimilate into the mainstream or accept societal assistance. Many arraign fate or bad luck for their situations but promise for a alter in their present circumstances.^{7 , 14}

Nursing considerations

Nurses may feel powerless and frustrated when caring for homeless patients. These patients' frequent ED visits and poor adherence to discharge instructions can contribute to burnout in nurses.¹ Yet nurses who larn nearly this culture'south unique needs are in a pivotal position to meliorate healthcare for this population.

Nurses need to empathise their personal values and beliefs before serving this population.⁵ The everyday lives of healthcare providers and the homeless are so different that they tin become cultural strangers, often avoiding contact with each other because of mutual fears. Some healthcare providers prescribe treatment and offer professional advice in hospitals, clinics, or shelters without understanding a patient's lifestyle or knowing if the patient lives on the street, in a wooded area, under a bridge, or in an SRO, parked car, railcar, tent, abandoned building, or cave.^{5 , 11}

According to R. Gonzales, managing director of operations of Halifax Urban Ministry, a multiservice agency serving the homeless in Daytona Beach, Fla., most homeless people protect the place where they live, fifty-fifty if it'due south outdoors, and carefully hibernate their things somewhere nearby.^xv

Ms. T said, "Waterproof backpacks are essential. And bikes. I sold my claret and an envelope of Keflex to purchase a two-wheeler." Both items facilitate a homeless person's ability to motility effectually within the community.¹⁵

Healthcare for the homeless is provided in various settings—shelters, infirmary EDs, store-front clinics, churches, and mobile van units. Appointments shouldn't be required. Although it's non always feasible, the multidisciplinary squad/case-management approach works best to prevent patient interest with multiple providers and fragmentation of care.¹¹

Outreach and example-finding is important. Edifice rapport is easier if patients are met on their own turf—shelters, soup kitchens, and on the street. Be enlightened of common factors that hinder treatment and work to overcome them. (See Barriers and obstacles to treatment.) Considering the overall picture for each person, family unit, and community differs, care needs to be planned co-ordinate to each person's potential.^{six , x}

Take enough time and practice patience to develop a trusting, nonjudgmental relationship that conveys respect, dignity, and value. Treat each person as an individual and avoid stereotyping. Follow up on promises. Be enlightened of the patient'southward body language and reply appropriately. Follow the patient'due south lead and respect his or her comfort level when making eye contact and inbound personal space. Speak in a calm manner, especially if the patient appears tense or nervous. Communicate in the person'south primary language; if necessary, use a medical interpreter.^{6 , thirteen}

Listen to the patient's stories to find mutual themes. Storytelling helps people create their own identities and bring the past to the present. Often-repeated stories may offering clues to the patient's concerns and anxieties and convalesce feelings of confusion.¹⁶ On many occasions, Ms. T recounted anecdotes from her previous piece of work experience equally an administrative assistant to a business organization executive. These stories, whether they're true or not, illustrate her need for respect and validation of her intelligence and contributions to social club.

Ask simple, open-ended questions with enough uninterrupted fourth dimension for the patient to answer. An interesting way to first a chat is, "What would make your 24-hour interval better right now?" Allow the patient set the pace of the interaction and follow his or her lead, beingness aware of eye contact and personal infinite. Tailor questions to the patient'due south housing and behavioral situation. Constitute articulate guidelines and appropriate personal boundaries.^ane Set limits on disrespectful comments, sexual innuendo, and obscene language. At times, making the paw gesture T signifying "time out" helps here. If not, make a firm statement. Personal safety is a business organisation for nurses working independently because some homeless people occasionally deport unpredictably.^x

Concrete and psychosocial assessment tin can be challenging. Focus beginning on bones life care needs. Pay special attention to the patient'due south teeth, skin, and feet considering homeless people accept express access to dental care, bathing facilities, and nutrient.^ane Exist alert for signs of substance corruption such as needle marks and nasal abnormalities.^xiii Assess for signs and symptoms of malnutrition, infectious diseases, lice, and scabies. Illicit drug utilize and risky sexual behaviors, including prostitution, increase the likelihood of infectious diseases such every bit HIV, hepatitis B and C, and STIs.

People residing in overcrowded living conditions accept a college incidence of airborne infections, especially tuberculosis and influenza.^{2 , 6} An uncommon but serious transmissible relapsing illness is Bartonella quintana, a louse-borne disease that causes fever, rash, bone pain, and splenomegaly. Complications include bacteremia and endocarditis.^{2 , 17}

Cess and intervention

Assess the patient'due south mental health for clarity of thought, emotional affect, and aggressive tendencies. Place areas of self-esteem, cocky-empowerment, and assertiveness, no thing how small, and determine the patient's personal, social, and day-to-solar day living skills. Focus and build on the patient's talents and strengths rather than on weaknesses. Place coping skills and areas of resilience—what worked before and what didn't. Prioritize problems.^{6 , 10}

Create viable care plans that are individualized and interdisciplinary. For acutely ill patients, coordinate appropriate intervention with medical facilities, mental wellness crunch units, or detoxification intendance.¹

For those not needing immediate intendance, develop patient-centered goals, expressed in the patient's language and frame of reference. The goals should belong to the patient, not the nurse. Make initial goals simple, physical, and brusk term. A very bones goal would be a return visit to the clinic the following twenty-four hour period. Registering for an identification bill of fare this afternoon is another example. Get-go at the get-go of the process instead of the hoped-for end consequence.^ten Patients must empathize the goals and believe they're attainable. Many homeless people may not be able to sustain interest in long-range endeavors. Their focus is the present mean solar day.

Chronic and infectious diseases should be managed with clear-cut treatment plans and medication schedules. Exist aware that the patient may sell his or her prescribed medications on the streets. Offer regular infectious disease screenings in shelters using multidisciplinary teams. Some of these screenings should be unannounced to cover people who'd stay away because they're agape or reluctant to interact with healthcare workers. If possible, give patients with terminal illnesses the opportunity for shelter and hospice-type interventions to relieve pain and suffering in a supervised setting.^{2 , 10 , xviii}

Coordination of care is imperative. Obtain previous records and place any back up persons in the patient's life.^x Services shouldn't conflict or duplicate each other; "one-stop shopping" and follow-upwardly with an assigned instance manager is optimal.¹³ If that's not possible, link services together to avoid fragmentation. Using the electronic medical record and following Health Insurance Portability and Accountability Act guidelines, patient wellness information can be shared with all providers so that handling plans and patient progress toward goals are managed more than finer.^{half dozen , thirteen}

If bachelor, utilise telehealth tools to communicate patient-specific data from mobile clinics to hospitals and healthcare provider offices.¹⁹ The U.S. Section of Housing and Urban Development'due south software programme, Homeless Direction Information Organisation, tin be used to record and store information about homeless people.²⁰

Investigate and network with the various disciplines and social service agencies that offer emergency overnight shelter, nutrient, hygiene products, and article of clothing, such every bit the Salvation Army, United Manner, churches, and soup kitchens.^{five , half-dozen} Coordinate services with city and county health departments, churches, and volunteer groups such as the Interfaith Hospitality Network. Refer homeless patients and those living in poverty to these customs agencies.

The paperwork maze is a tremendous trouble. Give patients detailed information most required paperwork, as well as agency locations, travel options, and the name of a contact person. Simply providing food, a rubber identify for vii or 8 hours of uninterrupted slumber, and an opportunity to shower improves patients' receptiveness to these services.^{five , 6 , xiv}

Learn near educational opportunities, job training programs, and free legal services. Refer patients to appropriate housing programs (emergency, transitional, or permanent). If appropriate, contact Habitat for Humanity and religious groups in the community. Agencies with comprehensive housing plans to address homelessness provide various options—emergency overnight shelter, transitional housing, permanent housing, and supportive housing (subsidized living arrangements with supportive services in place to meet the patients' needs).^{5 , 21 , 22}

Counsel patients to employ for state and federal programs such equally Medicare, Medicaid, welfare, Head Outset, Supplemental Security Income (SSI) program, and nutrient stamps. Typically, identification cards validating the person'southward proper name, birth engagement, and Social Security number are required.²¹ Some city governments or programs working directly with the homeless provide these free of charge.

Monies from the McKinney-Vento Homeless Assistance Act, a federal plan providing funds for outpatient health services, may be bachelor. Families with children are eligible to receive shelter and nutritional assistance from the Women, Infants and Children (or WIC) program, a federal program from the U.S. Department of Agronomics.⁵ Temporary Aid to Needy Families is a farther resource. Serious psychiatric and physical disability tin qualify patients for SSI.¹¹ The Homeless Emergency and Rapid Transition to Housing (or HEARTH) Act, signed into police in May 2009, consolidates the government's competitive grant programs and increases resources to forestall homelessness.²⁰ (See Tapping resource for more than information.)

Measure progress, provide positive reinforcement, and conform goals when necessary in a nonjudgmental way. Evaluate the success of the intendance programme objectives in measurable terms using evidence-based do criteria.^{10 , thirteen}

Nurse-managed health clinics (NMHC), especially those that serve only the homeless, provide a price-constructive solution for delivering healthcare to this population. Primary healthcare providers may exist NPs with prescriptive say-so, well prepared for the part.¹¹ Other squad members include dentists, physicians, substance abuse counselors, pharmacists, and psychologists. Nurses working in outreach and instance management tin deed every bit liaisons betwixt the homeless and NMHC staff. These one-on-ane relationships will increase the patients' participation in health screening and health promotion programs. NHMCs tin can provide clinical sites for nursing students and may operate under the aegis of hospitals, universities, or community colleges.^{1 , 23} The Patient Protection and Affordable Intendance Act of 2010 includes funding for nurse-managed centers.¹³

Customs health nurses can deed every bit case-finders and referral sources for the homeless and about-homeless. School nurses tin can identify and intervene with homeless students or those at run a risk and can offering educational programs on the needs of this population to the student body. Parish nurses can human action as a resource for persons needing shelter and educate the church building congregation on the characteristics of this elusive civilisation.

Focus on prevention

For virtually people, mental, physical, and financial problems precede homelessness; homelessness rarely comes first.^vi In 2011, the federal poverty guideline was $22,350 for a family of 4.⁵ To reduce the risk of homelessness, identify and intervene with individuals and families living in poverty and marginal situations, such equally families residing together in "doubled upwardly" situations.³ Assess for insect, mouse, or rat infestation; lack of running h2o; inadequate heating and air workout; malfunctioning plumbing; and the absenteeism of a telephone. Refer patients to emergency assistance programs for assist with rent and/or utility bills. Teach health promotion behaviors, such as using condoms, and screen for such diseases as tuberculosis, anemia, diabetes, and hypertension.^{5 , 24}

Advancement is important. Volunteer.^fourteen Talk to members of professional nursing organizations, political leaders, and the general public about the needs of the homeless and strategies to provide health screening and care in a humanitarian and cost-constructive manner. Mobile units with multidisciplinary teams are one choice; some other is attainable and convenient "brick and mortar" locations.²⁵ Many homeless people prefer to remain in their ain neighborhoods.

Each chronically homeless person who cycles in and out of homelessness and institutional care costs tens of thousands of dollars annually.²⁵ Offering documentation to local leaders showing that permanent supportive housing coupled with supportive intendance saves money because of the decreased fiscal burden on hospitals, mental health services, police and criminal justice resources, and substance abuse detoxification and treatment centers.²⁵ Government block grants are bachelor.

Crossing the split up

Homelessness today is a multifaceted public wellness problem. The Section of Wellness and Homo Services outlined several goals related to homelessness in Healthy People 2020: accomplish health equity, eliminate disparities, and create healthy social and physical environments.²⁶ Fifty-fifty though futurity research is essential to determine nursing's role in how to best achieve these goals, nurses have the skills and abilities to address this serious event in a humanitarian and cost-effective manner.¹⁴ Bridging the dissever betwixt the housed and the homeless will meliorate the health and well-being of society at large.

Now what about Mr. H, the man in the shelter? Toward the finish of my conversation with him, he jammed his fists in his sweatshirt pockets, saying, "I've gotta become out of hither," as he stomped out the door. Unfortunately, residents in the customs where he lives may experience the fallout from his anger and anxiety. I hope he'll return to the shelter for healthcare, counseling, and outreach services. Nursing intendance of the homeless must focus on both the needs of the individual patient and the population at big.⁶

Agreement two types of poverty⁵

The poverty of homelessness can be broken down into two subtypes: crisis poverty and persistent poverty.

• Crunch poverty impacts people whose lives are riddled with hardship and struggle; their homelessness is transient with episodic stays in shelters and temporary housing. The root causes of crisis poverty are lack of employment opportunities, obsolete task skills, lack of education, and domestic violence.
• Persistent poverty refers to chronically homeless people who are likely to have mental and concrete disabilities, which often be along with alcohol and drug corruption, family estrangement, lack of a high schoolhouse education, and poor social skills.

Nada in on chronic conditions

Homeless people have disproportionately high rates of these chronic atmospheric condition:

• arthritis
• asthma
• chronic obstructive pulmonary disease
• diabetes
• HIV/AIDS
• hypertension
• peripheral vascular disease
• pneumonia
• STIs
• tuberculosis (TB).^{5 , 6 , x}

The mental health diagnoses well-nigh often identified in the homeless are the following:

• bipolar disorder
• dementia
• depression
• personality disorder
• posttraumatic stress disorder
• schizophrenia.^{5 , 6}

Barriers and obstacles to treatment^{v , 6 , 10}

Keep in mind that a homeless patient may face up these hurdles:

• lack of transportation
• lack of phone service
• alienation from the healthcare system
• lack of preventive care
• literacy difficulties
• poor nutrition
• feelings of stigma
• multiple day-to-day stressors
• disorganization
• difficulty keeping appointments and adhering to medical plans
• clearing issues.

Tapping resources for more information

Bank check out these websites for more means to assistance homeless patients:

• National Brotherhood to End Homelessness: http://world wide web.endhomelessness.org
• National Wellness Treat the Homeless Quango: http://nhchc.org
• U.South. Department of Housing and Urban Evolution: http://portal.hud.gov.

REFERENCES

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fourteen. Nickasch B, Marnocha SK.Healthcare experiences of the homeless. J Am Acad Nurse Pract. 2009;21(1):39–46.

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