I had the opportunity to listen to a teleconference of state and county health department representatives discussing and reviewing proposed changes to Chapter 140 of the Department of Health Services (DHS) Administrative code.  I estimated 15 participants with a representative from the State Department of Health leading the discussion.  There was an attorney in attendance representing the interests of the County Health Departments. 

The process included comparing the existing chapter to the proposed changes.  I had a copy of both to follow during the teleconference.  At first I found the line by line and word by word comparison to be confusing, but quickly realized how important the process was.  Any accepted changes would be sent to the state legislature to be debated and voted on. These changes could possibly become law in the near future.   This process occurs about every 10 years.  In essence, the departments of health were proposing what they viewed their responsibilities and practice as public health departments to be for the next 10 years.  As a public health nurse, practice is population based.  The intervention of policy development includes the level of practice which is population based and system focused (Keller, Strohschein, Lia-Hoagberg, & Schaffer, 2004). The 5^th Intervention wedge encompasses advocacy, social marketing, policy development and enforcement (Keller et al., 2004).   By participating in this process, the public health nurse intervention was aimed at the community, the systems that affect the health of the community ultimately affecting the individuals in their communities.

In this experience my objective was to teach, interact and use the skills of what I had learned from my experiences, from my preceptor in public health. And I feel I did, by interacting with the children and teaching them to make healthy choices through songs and activities. This intervention of healthy teaching gives the children the knowledge to make choices they can benefit from along with their families. They will change their eating behaviors, practices, and attitudes. I went over to the WIC clinci and met with a WIC dietician. The intervention wheel describes the public health nurses’ practice, but there are other public health professionals such as nutritionists, planners, educators, physicians that use the same wheel in their practice (Olson Keller, Strohschein, Schaffer, & Lia-Hoagberg, 2004). WIC is one of the most successful programs, it provides nutrition education and counseling, nutritious food, and screening to low income pregnant women, breast feeding women, infants and children. They were receiving two new clients to the program, and recertifying other clients in the program. One of the new clients did not show up. I was really amazed at the WIC program, and the food that pregnant women and breastfeeding women get while in the program, along with their infants and children. I was really shocked. I felt, they should have to earn some of these commodities, not have it handed to them. It just doesn’t seem right, they are young teenagers that are able to put some time into the community for their commodities from the WIC program. I just feel they should be giving back to their community, for what they’re receiving. They could be volunteering their time or helping some of the elders in the community that are home bound. I realize their situations, but they got themselves in it. These are just my feelings, maybe I’m wrong to feel this way. But through WIC. women are having healthier babies by receiving early prenatal care, and infants born weigh more and are healthier. It’s been proven through evidence and research this program is a success.

I went with a PHN  employed by a local  Public Health Department but her office and work is in a low income hosing building.  She is the only nurse on staff and runs the resident’s Wellness Program in the building. Her salary is paid half by the Public Health Department  and half by a grant. The housing complex for low income individuals located. The requirements for living in the complex are:  family income may not exceed 50% of the median income for the county, seniors are eligible if they are over the age of 50 and meet the financial requirements. Funds for complex are provided by the Department of Housing and Urban Development (HUD) and from the rent collected from the residents. (Frequently Requested Housing Assistance Forms, 2010).  As the only nurse in the Wellness Program at this cokplex, the PHN performs all of the behind the scenes work as well as all of the patient care. One example is she got a resident set up with a Medic Alert bracelet, the resident signed the sheet and the PHN filled out the rest of the paperwork. We had a busy morning at the Wellness Clinic, filled with many appointments with mental health patients. At lunch time the PHN  said to me, “I know it’s been a crazy day but I really enjoy my job, it is very rewarding.” I was actually pretty surprised when she said that because I didn’t really find the day as rewarding, after dealing with several non-compliant patients. She did explain that the autonomy of the job makes the position worthwhile, however. Many of the residents at this apratment complex have mental health issues with no one to supervise if they are taking their antipsychotics appropriately. There is definitely the question of whether or not some of the residents are able to care for themselves. One resident reported that she observed another resident wearing the same clothes for two weeks and experiencing forgetfulness, yet on his last evaluation by protective services he was deemed capable of caring for himself. 

The suicide and seeking mental health treatment issues caught my attention, so I called the Crisis Center.  I talked to the employee at the Family Services Crisis Center who told me that involuntary commitment can only be determined by the police or a county representative, usually employed by the Crisis Center. The first person called (when suicide or homicide is a concern) is the police. The police then can determine if they want to get the Crisis Center involved (I found this strange because police are not healthcare professionals). Police are the first people called because safety is a legal issue and that is the main reason people are committed to mental health facilities involuntarily.How does the nurse determine if the resident/patient is a suicide risk? One of the main components is looking at the patients history, the Crisis Center told me. Has the individual had mental health issues in the past? Has the individual attempted suicide before? Obtaining a reliable history is particularly difficult for the PHN at this hosing complex because many of the residents do not have enough income to seek treatment and often come from living off the streets.  The second reason to suspect immediate danger is what the resident/patient verbalizes. The Crisis Center said there is a big difference between “I might be better off dead,” compared to “I want to die now.” At this point the nurse has to elaborate on the patient’s thoughts and plans regarding suicide. The next factor to look at is if the person feels safe. The nurse must assess if the person has a support system and if they feel safe by themselves. I have to admit when I was scheduled for a clinic day I  was not excited, as I have done my fair share of clinic work, but this was totally different than what I was expecting and I experienced a lot.

Recently discharged home from a nursing home after an acute care stay for hip surgery, Mabel (not her real name),  a 76 year old woman with low cognitive function, Parkinson’s disease, a speech impediment and a generally poor health appearance from years of questionable nutrition, was scheduled for a follow up home visit. The yard clutter and yellow windows signaled we were approaching a home in poor condition. Scattered litter, an empty kiddie pool, an oversized peeling plastic Santa yard ornament and a stack of over-stuffed, bursting garbage bags decorated the deteriorated wood porch with a sagging overhang and drooping  insulation.  We were met with the odor of urine and the sound of barking dogs from within as more than half a dozen mewing cats appeared out of nowhere and circled our legs, clamoring for affection.  Though she recently resided in a nursing home to recover from a hip surgery, Mabel was adamant about returning to this dwelling “ to die in my own home”, a phrase she repeated several times during our visit. A condition of her discharge was that she would have around the clock assistance as needed, but the adult daughter and boyfriend reportedly yelled at her, ignored her requests, and generally abandoned her. Most of the time during this experience, I was concerned primarily with my own safety, so my feeling was anxiety.  I feared being bit by the growling dogs whom I repeatedly kneed, stepping in filth, or becoming infested with some malady.  I was grossed out! Later, I tried to imagine what it had been like to live in this house, in these surroundings, in this family. I wondered about the life she had lived and the place she called home.  I reflected on the proudly displayed portraits of children and grandchildren and the perpetuation of the poverty and limited parenting through the generations.  Were my values and middle class upbringing clouding my vision of what constituted a home?  J.X. RN

This patient was first diagnosed with tuberculosis after undergoing treatment for esophageal cancer. He began having some difficulties breathing and decided to get it checked out. His answer was TB. At the time of his diagnosis, he was an active man and attended weekly card games with a group of friends. Under Wisconsin state statues, 252.02 – powers and duties of department and 252.03 – duties of local health officer, the door county public health department tested all parties that Cletus (not his real name) had contact with. They established a system for disease surveillance and inspection to monitor for further presence of the communicable disease. They also took prompt measures to suppress and control the disease by placing Cletus on isolation; the ability to do this is under statute 252.03 – duties of local health officer and 252.06 isolation and quarantine. Cletus remained on isolation until he had three consecutive negative sputum cultures which brought him to May of 2009, approximately six months after diagnosis. His treatment has been slow going due to his already compromised system. Once the client becomes non-communicable they no longer need to be on isolation, but the health officer or department may order directly observed therapy per statute 252.07 (5). Cletus will remain on directly observed therapy until May of 2010. So Monday through Friday, this public health nurse starts her morning with a directly observed therapy visit lasting approximately 30 minutes; allowing for medication administration and pleasant conversations.
While talking with Cletus the question came up regarding how and where? Through the state investigation, Cletus was linked to a strain of TB found on Broadway in New York City in the 1970’s and 1980’s, but how could a man from Wisconsin be linked to a bacterium from NYC? Cletus then informed me that he had a business on Broadway during the 70’s and did frequent many local establishments and must have become infected at that time. The bacterium remained latent until the cancer treatment compromised his immune system; turning the latent TB into active.
As I drove to this visit so many things went through my mind. I wondered how this person lived; actually thought about how dirty the apartment may be. Knowing the area of town that I was going and listening to others talk about how it wasn’t such a good place to be anymore made me very nervous. I am embarrassed to say this but I also wondered what type of person contracts active TB. Well in this case, a very nice man with a family who just ended up having some bad luck. Cletus moved to the area for convenience of family and doctors, does not work anymore but does occasionally get out to auctions and volunteers through the Optimist Club. The cancer may be gone but the medication regime he is on doesn’t make him feel the best. Thinking back on how I pictured Cletus to be makes me irritated with myself; that I could be so insensitive. Everyone deserves not to be judged by our circumstance and if I took anything away from this visit that is it. We must not form opinions of others without knowing the whole story. C. RN

I accompanied a public health nurse to a school vision screening. One student was asked if the letters looked blurry and he said “Yes, the letters are blurry, but my brother needs his glasses first; so I just do my best”. His ability to see according to the screening tool is approximately 80/20. Some of the public health interventions observed during this experience were: screening, case finding, delegated functions, and collaboration. Screening is obvious, with the use of certain vision tools we were able to identify children that may be at risk and who need further evaluation by an eye care provider. Case finding may be used after the letters go home on the children who need further evaluation. Families may be in need of assistance for what ever reason and the RN could then potentially connect them with the needed resources. There were four other people assisting the public health nurse with the screening process. She entrusted us to perform our duties proficiently, allowing the screening process to move smoothly. This was the public health nursing intervention of delegation of functions. Lastly, the nurse was the ability to develop collaboration between the public health department and the public schools; each looking to address possible health concerns of the children.
According to Webster’s Dictionary, it is a system of moral standards or the standards of conduct and moral judgments. Why is it that we place the people of the developing countries higher that the citizens of the US? Is it right for their children to see but not the children of the US? Being apart of this screening process has made me realize that some of our systems in place like the vision screening, do not allow for total success. We send people in to screen children, help others become aware of a potential problem but can’t always fix the problem. C. RN
From the Public Health Nursing Instructor: One of the most important roles in public health nursing is searching for resources for patients in need. Resources for vision screening services vary by state and school district, but here are a few programs set up to help kids who need glasses globally to locally:
• American Optometric Association program Vision USA: http://www.aoa.org/visionusa.xml
• LensCrafters and Luxotta program One Sight: http://www.onesight.org/
• Local Lions’ Club: http://lionsclubs.org/EN/lci-foundation/our-programs/sightfirst/initiatives/lcif-gr-sight-sightforkids.php
• VSP Sight for Students : http://www.sightforstudents.org/
• Prevent Blindness America: http://www.sightforstudents.org/
• Healthy Vision 2010 (NIH): http://healthyvision2010.nei.nih.gov/exams/preschool.asp

I accompanied a public health nurse to one of the three Head Start buildings. I thought the three year old children are too small to be in school, I felt they are just babies. I had thought the Head Start program was pre kindergarten, and the children learned the basics such as colors, numbers and the alphabet. I felt very ignorant learning we have so much to offer our children. But I guess I never ventured out side my box and now that I have, I am happy to know there are programs for children to help them grow socially, mentally, physically and emotionally. Head Start gets the child ready for kindergarten and ready to succeed, by learning self confidence, problem solving, improve their listening and speaking skills. They also learn to work together on different projects with their classmates. Children learn by playing together especially on their monitored safe playgrounds. The children are taught proper nutrition and are fed one balanced meal a day, along with a snack. They are also taught proper hygiene and dental care. They also have early Head Start, which starts when the mother is pregnant until the child is three years old and goes to Head Start. The public health nurse is her advocate and will utilize every intervention from the wheel for this individual and child. For first time mothers the public health nurse is her teacher and will introduce her to different resources. This intervention is called outreach. She will make referrals and follow-up appointments, to different resources such as social and supportive services, prenatal care, nutrition, dietary counseling, pregnancy and parent education. B. RN

Assisting with the health fair at a lcoal industry was a new experience for me. For the first time, I was exposed to the awesome responsibility of educating the public. It was no longer about helping the individual in the hospital setting, it was about making sure that I had the right information that would hopefully influence multiple lives for the better. As stated in one of my objectives, I approached this experience with an open mind, seeking to gain a greater understanding of health care at the community level. Along with a partner, we were assigned to a booth addressing child and infant safety issues. Specifically, we were asked to cover car seat safety and infant safety. I discovered that while running the booth at the health fair, many participants appeared to barely hear the latest recommendations and instead would ask, “What is the law?” My objective started to change as the health fair progressed to: how do I help guide these parents into seeing the bigger picture? While at the health fair, I was focusing on the individual, as I have been trained to do for the last fifteen years. This placed me within the Public Health Intervention Model (PHI) of “health teaching at the individual level” (Olson Keller, Strochschein, Lia-Hoagberg, & Schaffer, 1998). I had gathered, organized, and then relayed information to each person who walked by the booth. I was proud of the fact that I was able to engage individuals and customize my approach to each of their situations. I now ask myself, what could I have done to take this teaching topic up to the next level – teaching with a community focus? In order to have taught at a community level, I could have connected individuals with first-hand car seat experience with those who were not aware of the importance. M. RN

I had the opportunity to explore the role of a nurse medical examiner. The nursing interventions for many non-natural deaths includes collaboration and consultation. I thought it was interesting how procedure such as Statute 979.012 dictates who and under what circumstances deaths must be reported to the DHHS and local health department within 24 hours. The listing includes all homicides, suicides, after abortion, accidents that result in death (including surgeries), all pertaining to poisoning, and when no physician has been in attendance in the last 30 days (Wisconsin Legislative Council, 2005). One thing that was mentioned in the video that could lower the stressfulness of the circumstance is to remember that the body is already dead and is not going to need to be anywhere quickly. The consulting method is defined under WI State statutes and gives the medical examiner the ability to collect certain information to make accurate determinations. This is a service that many may be taking for granted but, rest assured we have a straightforward legislation guiding the practices of coroner’s and medical examiners that will be there if they are needed. T. RN

I went on a home visit with my public health nurse. We were going to visit the home of an 18yr mother with a 13 month old daughter. The father of the baby had signed off his rights to the child, never seen her and was no longer in contact with the mother. The mom lived with her mother, 26yr old brother, and brother’s girlfriend. They all lived in a small trailer in the trailer park. The child was unable to gain weight due to constantly regurgitating her formula. The weight issues had resolved. The mother expressed concern that her mother was a major caregiver of the child. The program is for “healthy families” and this was what her family was comprised of. If the grandmother was helping and caring for the child a large portion of the time would this not benefit the child for her to know the things they were teaching at the meetings? The visit was concluded by the PHN saying she would call the director of the program and discuss the situation with the mother’s permission. She would follow up as information was received. The mother agreed and seemed happy to have assistance. The experience met my learning objectives by teaching me what the community health nurses role is, what it takes to be effective and what I would need to posses if I ever considered being a community health nurse. This was a very interesting case for me because it gave a prime example of how a nurse works in the community. How she can be an effective tool in the community. According to WI State Ch 48 Statute, WI must provide to provide child centered, family focused supports aimed at promoting the health and well-being of children and families. All of the above interventions did just that. The child was the center focus. The family had the support of the PHN, Healthy Families, and etc. The child’s health improved along with her and her family’s well-being. M. RN