*Ethnopharmacology:*Ethnopharmacology:Cultural Issues & Genetic InfluencesCultural Issues & Genetic Influences

Dr. Barbara Jones Warren, Dr. Barbara Jones Warren, PhD, APRN, BCPhD, APRN, BC

*Please note that this is the intellectual property of the author and material is not to be copied, duplicated, or used without

permission of the author. Thank you.

ObjectivesObjectives

Examine issues of culture and Examine issues of culture and genetics as they relate to care of genetics as they relate to care of persons by advanced practice persons by advanced practice nurses.nurses.

Describe issues of culture as they Describe issues of culture as they relate to advanced clinical relate to advanced clinical interviewing & assessment interviewing & assessment techniques.techniques.

Let’s Talk About Definitions Let’s Talk About Definitions

Office of the Surgeon General. (2001). Mental health: Culture, race, & ethnicity. Rockville, MD: DHHS.

Culture:Culture: norms, values, and beliefs norms, values, and beliefs that provide meaning for an that provide meaning for an individual, group, or community’s individual, group, or community’s life.life.

Ethnicity:Ethnicity: common heritage shared common heritage shared by a particular group. by a particular group.

Race:Race: often thought of as genetic often thought of as genetic determinants within an individual’s determinants within an individual’s biological make-up. biological make-up. HoweverHowever, the , the most Surgeon General states, most Surgeon General states, “Different cultures classify people “Different cultures classify people into racial groups according to a set into racial groups according to a set of characteristics that are of characteristics that are sociallysocially significant. In fact, there is research significant. In fact, there is research that indicates there are greater that indicates there are greater genetic variations genetic variations withinwithin a racial a racial group than group than acrossacross racial groups.” racial groups.”

Health:Health: “word symbol” that provides “word symbol” that provides forward movement of the personality and forward movement of the personality and other ongoing human processes which other ongoing human processes which leads to creative, constructive, productive, leads to creative, constructive, productive, personal, & community living.personal, & community living.

EnvironmentEnvironment:: physiological, physiological, psychological, and social fluidity for the psychological, and social fluidity for the client and APRN.client and APRN.

Ethnopharmacology:Ethnopharmacology: the study of the study of pharmacologic responses for persons from pharmacologic responses for persons from different racial and ethnic backgrounds.different racial and ethnic backgrounds.

Campinha-Bacote, J. (2003). Presentation on Ethnic pharmacology: A neglected area of cultural competency in nursing education, practice, & research.

Peplau, H. Interpersonal Relations.

Current State of the KnowledgeCurrent State of the Knowledge There are biological basis for There are biological basis for

variations or differences in metabolic variations or differences in metabolic response to agents.response to agents.• Genetics and polymorphism in drug Genetics and polymorphism in drug

metabolismmetabolism• Multiple disease statesMultiple disease states• Drug to drug interactionsDrug to drug interactions

EnvironmentalEnvironmental• Diet, smoking, pregnancy, stress, Diet, smoking, pregnancy, stress,

diurnal rhythmsdiurnal rhythmsWarren, B. J. & Jann, M. W. (2003). Presentation @ Sharing Our Skills Meeting,

Cultural Issues in Mental Health: Part I, II.

Current State of the KnowledgeCurrent State of the Knowledge

CulturalCultural• Attitudes, beliefs, family influences and Attitudes, beliefs, family influences and

therapy expectations.therapy expectations.• Genetic responses are variant and may Genetic responses are variant and may

cause higher response & higher risk for cause higher response & higher risk for more intense negative side effects. This more intense negative side effects. This is where cultural competence and is where cultural competence and physiology meet physiology meet create quality, create quality, culturally responsive care for clients.culturally responsive care for clients.

Warren, B. J. & Jann, M. W. (2003). Presentation @ Sharing Our Skills Meeting, Cultural Issues in Mental Health: Part I, II.

Biological Basis for DifferencesBiological Basis for Differences

Genetics and polymorphism in drug Genetics and polymorphism in drug metabolismmetabolism• Specific DNA regions on various Specific DNA regions on various

chromosomes influence hepatic chromosomes influence hepatic metabolismmetabolism

• Polymorphism: defined at least 2 distinct Polymorphism: defined at least 2 distinct groupsgroups

Warren, B. J. & Jann, M. W. (2003). Presentation @ Sharing Our Skills Meeting, Cultural Issues in Mental Health: Part I, II.

Biological Basis for DifferencesBiological Basis for Differences Various types of hepatic metabolism Various types of hepatic metabolism

– 2 phases– 2 phases• Acetylation: INH, hydralazine, Acetylation: INH, hydralazine,

procainamideprocainamide• Oxidation: P450 isozymesOxidation: P450 isozymes• Glucuronidation: lorazepam,Glucuronidation: lorazepam,

only phase IIonly phase II• Cholinesterase in plasmaCholinesterase in plasma• Dehydrogenases: alcoholDehydrogenases: alcohol

Warren, B. J. & Jann, M. W. (2003). Presentation @ Sharing Our Skills Meeting, Cultural Issues in Mental Health: Part I, II.

Cultural CommunicationCultural Communication

Cultural Competence is Critical for Cultural Competence is Critical for Clients and FNPsClients and FNPs

This process includes:This process includes:• Behavioral PerspectiveBehavioral Perspective• Individual PerspectiveIndividual Perspective• Self or Outside PerspectiveSelf or Outside Perspective

All are related to biopsychosocial All are related to biopsychosocial components within persons.components within persons.

Cultural CompetenceCultural CompetenceProcess of knowing, appreciating, & valuing Process of knowing, appreciating, & valuing cultural differences and variations while cultural differences and variations while incorporating such into your area of nursing incorporating such into your area of nursing expertise as well as in your relationships and expertise as well as in your relationships and interactions with others.interactions with others.

RelationshipRelationshipValueValue

AppreciationAppreciation

CulturalCulturalVariationsVariations

CulturalCulturalInterviewInterview

Warren, B. J. (2003). Cultural and ethnic considerations. In D. Antai-Otong, Psychiatric nursing: Biological & behavioral concepts, (pp. 151-165). NJ: Thomson Delmar Learning.

Critical to development of a successful Critical to development of a successful cultural clinical interview process.cultural clinical interview process.

Involves the client & MH provider’s cultural Involves the client & MH provider’s cultural perspectives re: healthcare practices, beliefs, perspectives re: healthcare practices, beliefs, and importance of the environment. and importance of the environment.

This provides a unique experience, This provides a unique experience, development of expectations and pattern of development of expectations and pattern of interactions.interactions.

The APRN guides the:The APRN guides the: • Significant, therapeutic, interpersonal processSignificant, therapeutic, interpersonal process• Forward movement of personalities involved in Forward movement of personalities involved in

the relationshipthe relationship

Interpersonal RelationshipInterpersonal Relationship

Cultural Perspectives within the Cultural Perspectives within the APRN Care ProcessAPRN Care Process

World ViewsWorld Views

THINKING INTERACTING

World Views:World Views: represents what a person values & represents what a person values & how they functionhow they function

ANALYTIC

RELATIONAL COMMUNITY

ECOLOGICAL

Warren, B. J. (2002). The interlocking paradigm of cultural competence: A best practice approach. Journal of the American Psychiatric Nurses Association, 8 (6), 209-213.

Clinical InterviewingClinical Interviewing

World ViewsWorld Viewsrepresents what a person values & how they functionrepresents what a person values & how they function

AnalyticAnalytic (systematic): (systematic): OUTCOME ORIENTEDOUTCOME ORIENTED

RelationalRelational (interactions with others): (interactions with others):RELATIONSHIP-BASEDRELATIONSHIP-BASED

CommunityCommunity (needs of the group):(needs of the group):TRANSENDENCE-MOTIVATEDTRANSENDENCE-MOTIVATED

Ecology Ecology (connection with the earth):(connection with the earth):ECOLOGY-BASEDECOLOGY-BASED

Warren, B. J. (2002). The interlocking paradigm of cultural competence: A best practice

approach. Journal of the American Psychiatric Nurses Association, 8 (6), 209-213.

Cultural Interviewing StrategiesCultural Interviewing Strategies

Involves the preservation of the Involves the preservation of the client’s culture in a recovery-based client’s culture in a recovery-based context.context.

Utilizes negotiation to develop and Utilizes negotiation to develop and extend the healthcare process and extend the healthcare process and provide evidence-based holistic provide evidence-based holistic health care for the client.health care for the client.

Utilizes critical thinking regarding Utilizes critical thinking regarding cultural competence in order to cultural competence in order to repattern the client’s approach to repattern the client’s approach to addressing their health needs and addressing their health needs and symptom management.symptom management.

Dr. Madeline Leininger, 1995

Interviewing StrategiesInterviewing Strategies

• Holistic Perspective

• Mental Health & Wellness

• Spiritual Connection

• Physiological Components

Culture – Focused InterviewCulture – Focused Interview

Focuses on the Focuses on the interpersonal interpersonal dynamic process dynamic process in order to help in order to help the client define the client define his or her his or her symptoms, symptoms, needs.needs.

Culturally CompetentCulturally CompetentHealthcare IssuesHealthcare Issues

Genetic and ethnic influences.Genetic and ethnic influences.

Cultural health beliefs and practices.Cultural health beliefs and practices.

Environmental variables (living, Environmental variables (living, rearing, persons around a client).rearing, persons around a client).

Culturally CompetentCulturally CompetentHealthcare Issues [Cont.]Healthcare Issues [Cont.]

Healthcare professionals’ cultural Healthcare professionals’ cultural perspectives and cultural competence perspectives and cultural competence knowledge.knowledge.

Client & others’ perspective & knowledge Client & others’ perspective & knowledge of cultural processes.of cultural processes.

Cultural Interview GuidelinesCultural Interview Guidelines LLISTEN to the client.ISTEN to the client. EEXPLAIN your XPLAIN your

perception of what the perception of what the client said.client said.

AACKNOWLEDGE the CKNOWLEDGE the importance of the importance of the client’s cultural client’s cultural perspectives.perspectives.

RRECOMMENDATIONS ECOMMENDATIONS are made according to are made according to the APRNs expertise the APRNs expertise and the client’s cultural and the client’s cultural health needs.health needs.

NNEGOTIATE to obtain EGOTIATE to obtain successful, culturally successful, culturally competent healthcare.competent healthcare. Berlin & Fowkes, 1982

Cultural Interviewing SuggestionsCultural Interviewing Suggestions

Meaning of wellness & Meaning of wellness & distress.distress.

How s/he describe the How s/he describe the symptoms of current distress. symptoms of current distress.

Feelings about seeking Feelings about seeking healthcare, issues of stigma.healthcare, issues of stigma.

How others who are How others who are important to the client feel important to the client feel about s/he seeking help for about s/he seeking help for illness/ distress.illness/ distress.

Cultural practices for treating Cultural practices for treating illness/ distress.illness/ distress.

(Gaw, 2001)(Gaw, 2001)

Assess client’s cultural perspectives regarding:Assess client’s cultural perspectives regarding:

*WHAT THEY NEED FROM YOU?*WHAT THEY NEED FROM YOU?

Culturally Competent EducationCulturally Competent Education* Provide Client Education Regarding:• Symptoms of their disorder/ distress.• Treatment approaches as they relate to their cultural

practices.• Daily schedule needs (e.g., dietary practices, work,

sleep, etc.)• Role & use of support systems (e.g., healthcare

professionals, family, significant others)• Through individual &/or group health sessions

(Colom, et al., 2003)

BrokeringBrokering Negotiation is the Negotiation is the

key for successful key for successful evidence-based evidence-based holistic healthcare holistic healthcare interviewing, interviewing, assessment, assessment, treatment & treatment & follow-up!follow-up!

Cultural InterviewingCultural Interviewing

Interface of biological, psychological, Interface of biological, psychological, and social theoretical evidence-based and social theoretical evidence-based therapeutic foci into a therapeutic foci into a highly highly specializedspecialized approach to client care. approach to client care.

The focus is on the interaction and The focus is on the interaction and relationship in order to obtain accurate relationship in order to obtain accurate client assessment data. client assessment data.

Cultural Client InterviewingCultural Client Interviewing

Communication

Orientation

Significant Others

Health Beliefs

Education

Biopsychosocial Issues: Mind-body-spirit

Involves the interpersonal processes between you, Involves the interpersonal processes between you, the client, and others important for both of you!the client, and others important for both of you!

Healthcare Professional’s Cultural Healthcare Professional’s Cultural PerspectivePerspective

Disparities in mental healthcare may Disparities in mental healthcare may be influenced by societal and provider be influenced by societal and provider perspectives as they relate to racially perspectives as they relate to racially and ethnically diverse persons.and ethnically diverse persons.

Institute of Medicine, Committee on Understanding and Institute of Medicine, Committee on Understanding and Eliminating Racial and Ethnic Disparities in Healthcare. (2002). Eliminating Racial and Ethnic Disparities in Healthcare. (2002). Unequal treatment: Confronting racial and ethnic disparities in Unequal treatment: Confronting racial and ethnic disparities in healthcare. healthcare. Washington, DC: National Academy Press. Washington, DC: National Academy Press.

Institute of Medicine, Committee on Health and Behavior. Institute of Medicine, Committee on Health and Behavior. (2001). (2001). Health and behavior: The interplay of biological, Health and behavior: The interplay of biological, behavioral, and societal influences. behavioral, and societal influences. Washington, DC: National Washington, DC: National Academy Press.Academy Press.

Biopsychosocial Issues & Biopsychosocial Issues & Medication AdherenceMedication Adherence

Genetic and ethnicity influencesGenetic and ethnicity influences Cultural health beliefs and practicesCultural health beliefs and practices Environmental variablesEnvironmental variables Healthcare professionals’ cultural Healthcare professionals’ cultural

perspectivesperspectives Client’s perspective of recovery Client’s perspective of recovery

processprocess OUTCOME OUTCOME Treatment/action plan for Treatment/action plan for

client.client.

Cultural Influences onCultural Influences onDosing DecisionsDosing Decisions

Body Weight Body Weight

Smoking & Smoking & Alcohol ConsumptionAlcohol Consumption

Diet & Nutritional Diet & Nutritional FactorsFactors

ClinicianClinicianPrescribingPrescribingPracticesPractices

ClientClientRace & EthnicityRace & Ethnicity

AgeAge

Biological Biological SexSex

Frackiewicz, et., al. (1999). Review of neuroleptic dosage in different ethnic groups. In J. M. Herrera, et al., (Eds.), Cross cultural psychiatry (Chapter 11). NY: Wiley

Client Cultural Client Cultural Health Beliefs & PracticesHealth Beliefs & Practices

Cultural dietary practices may alter Cultural dietary practices may alter metabolism of medication and thus metabolism of medication and thus affect medication affect and affect medication affect and subsequent client adherence.subsequent client adherence.

(Gaw, 2001)(Gaw, 2001) 40% of HMO clients use herbs without 40% of HMO clients use herbs without

their provider’s knowledge.their provider’s knowledge.(Bennett & Brown, 2000)(Bennett & Brown, 2000)

Culturally Responsive Access to Culturally Responsive Access to Healthcare for ClientsHealthcare for Clients

AvailableAvailable

AccessibleAccessible AffordableAffordable

AcceptableAcceptable

AppropriateAppropriate

CulturalCultural Responsive Responsive

AccessAccess

Campinha-Bacote, J. (2003). The process of cultural competence in the delivery of healthcare services. Cinti, OH: Author.

Client Recovery ProcessesClient Recovery ProcessesClient Recovery ProcessesClient Recovery Processes

Client-ProviderClient-ProviderCultural Cultural

InteractionsInteractions

HealthcareHealthcareSystem System

EnvironmentEnvironment

Client EnvironmentalClient Environmental ConditionsConditions

CulturallyCulturallyCompetentCompetent

Assessment StrategiesAssessment Strategies

EthnopharmacologEthnopharmacologyy

Client InfluencesClient Influences

Psycho-TherapeuticPsycho-TherapeuticInterventionsInterventions

RecoveryRecoveryProcessesProcesses

Hogan, M. H. (2003). Report of the President’s New Freedom Commission on Mental Health. Washington, DC: National Academy Press.

Warren, B. J. (2002). Interlocking paradigm of cultural competence. Journal of the American Psychiatric Nurses Association, 8(6), 208-213.

Cultural Assessment of Client Cultural Assessment of Client Medication AdherenceMedication Adherence

Feelings about taking Feelings about taking medicationmedication

Meaning of taking medicationMeaning of taking medication How others who are important How others who are important

to you feel about you taking to you feel about you taking medicationmedication

Religious attitudes about Religious attitudes about taking medicationtaking medication

Benefits of taking medicationBenefits of taking medication Any meaning re: color, size, or Any meaning re: color, size, or

form of medication form of medication Concerns of losing control Concerns of losing control

when using medication.when using medication.(Gaw, 2001)(Gaw, 2001)

Assess client’s cultural perspectives regarding:Assess client’s cultural perspectives regarding:

Cultural Assessment of Client Cultural Assessment of Client Medication AdherenceMedication Adherence

• Symptoms of their disorderSymptoms of their disorder• Medication action and side effect profileMedication action and side effect profile• Influence of herbal preparations with Influence of herbal preparations with

prescribed medication for their disorderprescribed medication for their disorder• Daily schedule (e.g., dietary practices, Daily schedule (e.g., dietary practices,

work, sleep, etc.)work, sleep, etc.)• Role & use of support systems (e.g., Role & use of support systems (e.g.,

healthcare professionals, family, healthcare professionals, family, significant others)significant others)

• Through individual &/or group sessionsThrough individual &/or group sessions(Colom, et al., 2003)

Provide Client Education Regarding:Provide Client Education Regarding:

Medication AdherenceMedication Adherence Influenced by genetic patterns, Influenced by genetic patterns,

CYP2D6, specific alleles are now CYP2D6, specific alleles are now being defined that are involved in the being defined that are involved in the metabolic process. metabolic process.

Influenced by dietary practicesInfluenced by dietary practicesCorn in Latina populations (slows Corn in Latina populations (slows medication metabolism).medication metabolism).

Lin, K., Smith, M. W., & Mendoza, R. P. (1999). In Herrera, et al., (Eds.), Cross cultural psychiatry (pp. 45-52). New York: John Wiley & Sons.

Herrera, et al., (1999). Cross cultural psychiatry. New York: John Wiley & Sons.

Medication AdherenceMedication Adherence

Influenced by use of herbal Influenced by use of herbal preparations.preparations.

Influenced by health care beliefs and Influenced by health care beliefs and practices.practices.

Lin, K., Smith, M. W., & Mendoza, R. P. (1999). In Herrera, et al., (Eds.), Cross cultural psychiatry (pp. 45-52). New York: John Wiley & Sons.

Herrera, et al., (1999). Cross cultural psychiatry. New York: John Wiley & Sons.

Biocultural EcologyBiocultural Ecology

INVOLVES:INVOLVES: PharmacogeneticsPharmacogenetics PharmacokineticsPharmacokinetics PharmacodynamicsPharmacodynamics Biocultural Ecology:Biocultural Ecology:

• Skin Color and Biologic VariationsSkin Color and Biologic Variations• Diseases and Health ConditionsDiseases and Health Conditions• Variations in Drug MetabolismVariations in Drug Metabolism

Purnell, L., & Paulanka, P. (1998). Purnell’s model for cultural competence. In L. Purnell & P. Paulanka (Eds.).,Transcultural healthcare: A culturally competent approach (pp. 7-51). Philadelphia: Davis.

PharmacologyPharmacology

Medication Action:Medication Action:

• Target EffectsTarget Effects• Unwanted SEUnwanted SE• Toxic EffectsToxic Effects• Adverse EffectsAdverse Effects

Medication Mgt.:Medication Mgt.:

• PreventionPrevention• ContraindicationContraindication• Interactive SEInteractive SE

Metabolic PathwaysMetabolic Pathways

BREAKDOWN, DISTRIBUTION, FUNCTION

Debrisoquine-SparteineDebrisoquine-Sparteine

Medications metabolized through Medications metabolized through this pathway:this pathway:• AntiarrhythmicsAntiarrhythmics• Beta-blockersBeta-blockers• AntidepressantsAntidepressants• AntipsychoticsAntipsychotics• OpioidsOpioids

African, Native, & Asian-Americans African, Native, & Asian-Americans are more affected by their genetic are more affected by their genetic variations within this pathway. variations within this pathway.

Acetylation PathwayAcetylation Pathway This pathway is an important factor This pathway is an important factor

in the determination of the rate of in the determination of the rate of metabolism.metabolism.

Definition of terms:Definition of terms:• Extensive (“Extensive (“normalnormal”” reaction) reaction)

metabolizersmetabolizers• Slow (“Slow (“prone to toxic reactionsprone to toxic reactions”) ”)

metabolizersmetabolizers Caucasian & African-Americans: 50% (slow)Caucasian & African-Americans: 50% (slow) Egyptians and Moroccans: 80% - 90% (slow)Egyptians and Moroccans: 80% - 90% (slow) Asian-Americans: 5% - 15% (slow)Asian-Americans: 5% - 15% (slow)

MephenytoinMephenytoin

Medications metabolized within this Medications metabolized within this pathwaypathway• AntianxietyAntianxiety• TBTB• CaffeineCaffeine• Cardiovascular Cardiovascular • TranquilizersTranquilizers

Asian and European populations are Asian and European populations are more susceptible to genetic variations more susceptible to genetic variations within this pathway. within this pathway.

OxidationOxidation

Research has identified specific CYP450 Research has identified specific CYP450 isozymes involved in polymorphism. isozymes involved in polymorphism. Genotyping is the current approach for Genotyping is the current approach for DNA determining genetic variations.DNA determining genetic variations.• 2D6: beta blockers, antipsychotics, tricyclic 2D6: beta blockers, antipsychotics, tricyclic

antidepressantsantidepressants 7 alleles have been identified which will make 7 alleles have been identified which will make

prescribing even more effective for persons prescribing even more effective for persons with genetic variationswith genetic variations

• There are 5 for Caucasian-Americans, 10 for Asian-There are 5 for Caucasian-Americans, 10 for Asian-Americans, and 17 for African-AmericansAmericans, and 17 for African-Americans

OxidationOxidation CYP2C19: alleles 2 and 3 have been CYP2C19: alleles 2 and 3 have been

identified within this isozyme.identified within this isozyme.• Medications: diazepam, imipramine, Medications: diazepam, imipramine,

citralopam, mephobarbital, omeprazole.citralopam, mephobarbital, omeprazole.• Poor Metabolizers include:Poor Metabolizers include:

India Indians, Japanese & other Asian-India Indians, Japanese & other Asian-Americans: 15% - 21%Americans: 15% - 21%

Caucasian-Americans: 2% - 6%Caucasian-Americans: 2% - 6% African-Americans: 2%African-Americans: 2%

OxidationOxidation CYP1A2CYP1A2

• Women have a poor metabolizer Women have a poor metabolizer response and this require less doses of response and this require less doses of medications medications

• Smoking effects are located hereSmoking effects are located here• Some carcinogens are associated with Some carcinogens are associated with

this isozyme as wellthis isozyme as well• Charbroiled meat can intensify this Charbroiled meat can intensify this

responseresponse• Caffeine also affectsCaffeine also affects

Herbal TherapiesHerbal Therapies Tricyclic Tricyclic

Antidepressants and Antidepressants and Antipsychotics’ Antipsychotics’ actions are similaractions are similarto these herbs:to these herbs:• Swertia Japonica Swertia Japonica • Kamikihi-toKamikihi-to• Datura candidaDatura candida• Nigerian root extractNigerian root extract• South American hollySouth American holly

Interlocking Paradigm of Cultural CompetenceInterlocking Paradigm of Cultural Competence

THERAPEUTITHERAPEUTICC

FACTORFACTOR

THEORY FACTOR

ForClinician

PROCESSFACTOR

ForClinician

WORLD-VIEWFACTOR

For Clinician & Client

Copyright B. J. Warren, 2001

CommunitiesCommunities

WorldWorld

Other Persons’Other Persons’World ViewsWorld Views

ORIENTATIONFACTOR

For Clinician & Client

Process & Orientation Factors for Process & Orientation Factors for APRN & ClientAPRN & Client

CommunicationPatterns

Environmental& RearingOrientation

Significant Othersin the interactive

process

Health Beliefs

Education Level

Biopsychosocial Issues: Mind-body-spirit

Culturally Competent HealthcareCulturally Competent Healthcare

Case StudyCase Study(developed by Ms. Sarah Alley, RN, BSN)(developed by Ms. Sarah Alley, RN, BSN)

Mrs. Z is a 68 year old Japanese American who has lived alone Mrs. Z is a 68 year old Japanese American who has lived alone for the past 3-years since the death of her husband. Mrs. Z was for the past 3-years since the death of her husband. Mrs. Z was born in Japan & moved to the U.S. with her husband 25 yrs ago.born in Japan & moved to the U.S. with her husband 25 yrs ago.

Mrs. Z is retired after working many years as a seamstress. Mrs. Mrs. Z is retired after working many years as a seamstress. Mrs. Z has been referred to you (PMHAPN) by her primary care Z has been referred to you (PMHAPN) by her primary care physician for evaluation after presenting with complaints of physician for evaluation after presenting with complaints of difficulty sleeping, frequent stomach aches & low energy.difficulty sleeping, frequent stomach aches & low energy.

Physical exam & laboratory work were all WNL for the primary Physical exam & laboratory work were all WNL for the primary care physician & your physical exam of Mrs. Z has produced care physician & your physical exam of Mrs. Z has produced normal findings as well.normal findings as well.1.What genetic variables do you need to consider in this case?2.Think about differential diagnosis for your specialty practice.3.What referrals are needed that include other specialty APRNs? Remember you may not be able to handle every disorder on your own, know the boundaries of your practice.Hint: APRN, PMH nurses.

Case Study, continuedCase Study, continued(developed by Ms. Sarah Alley, RN, BSN)(developed by Ms. Sarah Alley, RN, BSN)

Mrs. Z appears tired, her clothes are wrinkled & she has on two Mrs. Z appears tired, her clothes are wrinkled & she has on two different shoes. Mrs. Z is currently taking OTC ibuprofen for different shoes. Mrs. Z is currently taking OTC ibuprofen for mild arthritis in her hands, however, she is not taking any other mild arthritis in her hands, however, she is not taking any other medications at this time. medications at this time.

Upon further discussion with Mrs. Z, you find out that her dog of Upon further discussion with Mrs. Z, you find out that her dog of 13 years passed away 3 weeks ago & her youngest daughter 13 years passed away 3 weeks ago & her youngest daughter just moved out of the house after graduating from college. just moved out of the house after graduating from college.

Mrs. Z needs reminding of where the bathroom is after her visit Mrs. Z needs reminding of where the bathroom is after her visit with you, although she went to the bathroom previously before with you, although she went to the bathroom previously before her examination. her examination.

Perhaps a review of dementia and depression is needed.

Additional ReferencesAdditional References(provided by Ms. Sarah Alley, RN, BSN)(provided by Ms. Sarah Alley, RN, BSN)

American Psychiatric Association. (2000). Diagnostic and American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders – (DSM-IV-TR). (4Statistical Manual of Mental Disorders – (DSM-IV-TR). (4thth ed.). ed.). Washington, D.C. : Author. Washington, D.C. : Author.

Baker, F. M. & Bell, C. C. (1999). Baker, F. M. & Bell, C. C. (1999). Issues in the Psychiatric Issues in the Psychiatric Treatment of African-AmericansTreatment of African-Americans. Psychiatric Services, . Psychiatric Services, 50 (3), 362-367.50 (3), 362-367.

Betchel, G.A., Davidhizar, R., Tiller, C. M. (1998). Betchel, G.A., Davidhizar, R., Tiller, C. M. (1998). Patterns of Patterns of Mental Health Care Among Mexican Americans. Mental Health Care Among Mexican Americans. Journal of Journal of Psychosocial Nursing, 36 (11), 20-23.Psychosocial Nursing, 36 (11), 20-23.

Haber, J., Krainovich-Miller, B., McMahon, A. L., Price-Hoskins, P. Haber, J., Krainovich-Miller, B., McMahon, A. L., Price-Hoskins, P. (1997). Comprehensive Psychiatric Nursing (5(1997). Comprehensive Psychiatric Nursing (5thth ed.). St. ed.). St. Louis: Mosby Year-Book, Inc. Louis: Mosby Year-Book, Inc.

Keltner & Folks (2001). Psychotropic Drugs (3Keltner & Folks (2001). Psychotropic Drugs (3rdrd ed.). St. Louis: ed.). St. Louis: Mosby Inc. Mosby Inc.

Mohr, W.K. (1998). Mohr, W.K. (1998). Cross-Ethnic Variations in the Care of Cross-Ethnic Variations in the Care of Psychiatric PatientsPsychiatric Patients. Journal of Psychosocial nursing, 36 (5), . Journal of Psychosocial nursing, 36 (5), 16-21.16-21.

Stahl, S. M. (2000). Essential Psychopharmacology Stahl, S. M. (2000). Essential Psychopharmacology Neuroscientific Basis and Practical Applications (2Neuroscientific Basis and Practical Applications (2ndnd ed.). ed.). New York: Cambridge Press New York: Cambridge Press

Ethnicity and HealingEthnicity and HealingEthnicity and HealingEthnicity and HealingEthnicity (e.g., culture) imprints every person…It binds Ethnicity (e.g., culture) imprints every person…It binds those common roots and separates them from those with those common roots and separates them from those with different origins. It suffuses body and oral language, as well different origins. It suffuses body and oral language, as well as the way we take in, or distance ourselves from the world as the way we take in, or distance ourselves from the world and other people.and other people.

Ethnicity (e.g., culture) is a force in both the genesis and Ethnicity (e.g., culture) is a force in both the genesis and healing of disease. It contributes to the uniqueness of the healing of disease. It contributes to the uniqueness of the experience of illness. It is the…obligation of every nurse to experience of illness. It is the…obligation of every nurse to comprehend and…empathize…with the cultural identity comprehend and…empathize…with the cultural identity of those he or she purports to provide care for.of those he or she purports to provide care for.

Pellegrino, E. (1992). Ethnicity and Healing. In M. G. Secundy, Trials, Tribulations, and Celebration: African-American Perspectives on Health, Illness, Aging, and

Loss, (p. xix). Yarmouth, ME: Intercultural Press.

COMMENTS, QUESTIONSCOMMENTS, QUESTIONS

WORK THROUGH THE FOLLOWING CASE STUDY IN ORDER TO WORK THROUGH THE FOLLOWING CASE STUDY IN ORDER TO PRODUCE A CULTURALLY COMPETENT APRN PLAN FOR THE CLIENT:PRODUCE A CULTURALLY COMPETENT APRN PLAN FOR THE CLIENT:

CONTACT INFORMATIONCONTACT INFORMATION

Dr. Barbara Jones WarrenDr. Barbara Jones Warren614-292-4847614-292-4847

FAX: 614-292-4948FAX: 614-292-4948

E-MAIL: E-MAIL: warren.4@osu.eduwarren.4@osu.edu