{"id":357,"date":"2021-08-28T02:29:48","date_gmt":"2021-08-28T06:29:48","guid":{"rendered":"https:\/\/pressbooks.library.ryerson.ca\/assessmentnursing\/?post_type=chapter&#038;p=357"},"modified":"2022-01-29T10:21:43","modified_gmt":"2022-01-29T15:21:43","slug":"health-promotion-2","status":"publish","type":"chapter","link":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/chapter\/health-promotion-2\/","title":{"raw":"Health Promotion and Disease Prevention: Considerations and Interventions","rendered":"Health Promotion and Disease Prevention: Considerations and Interventions"},"content":{"raw":"<p style=\"text-align: left\"><span style=\"color: #000000\">Health promotion and disease prevention are important components of a healthy respiratory system. To determine appropriate interventions, you should carefully consider all of the collected data, both subjective and objective. As part of subjective data collection, you should inquire about risk factors, social determinants, and other considerations.<\/span><\/p>\r\n<span style=\"color: #000000\"><span style=\"font-size: 1em\">The inquiry part is integrated throughout the assessment. Many of the probing questions may be asked when doing the subjective assessment. However, some of the questions will be formulated based on your critical reflection of data collected during the subjective and objective assessment. It is this data that will inform your clinical judgment and the health promotion needed for a specific patient.<\/span><\/span>\r\n<h2 style=\"text-align: left\"><span style=\"color: #000000\"><strong>Handwashing and Immunization: Self-Care Behaviours\u00a0<\/strong><\/span><\/h2>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Handwashing and immunization are two important factors that affect respiratory health. Regular handwashing is important in healthcare and work settings, when returning home, prior to making and eating food, and before and after elimination.<\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Probing questions related to handwashing and immunization include:<\/span><\/p>\r\n\r\n<ul style=\"text-align: left\">\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Tell me about when you wash your hands?<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">What is involved in washing your hands? (You may need to probe further: What are the steps involved? How long do you do it for?)<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Are you up to date on your vaccines?<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">When was your last vaccine? What was it for? (You may need to probe about specific vaccines such as influenza [flu], pneumonia, and COVID-19.)<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Have you had tuberculosis testing and when was your last chest x-ray? (You should ask about the results, if relevant). Asking these questions is important part of screening.<\/span><\/li>\r\n<\/ul>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">You may need to provide education about proper handwashing practices: when and how. Tell the client that it is important to wash hands frequently, but always when leaving a building, returning home, before and after meals, and before and after using the washroom. Tell them to wet their hands with water, lather with soap for 20 seconds, rinse and dry their hands, and then turn off the tap with their elbow or a paper towel. Consider how to make it fun with children: you could tell them to sing a song that lasts 20 seconds (e.g., Happy Birthday).<\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">With regard to vaccines, consider the recommended schedule based on age and region. In Canada, vaccine schedules are determined by provinces and territories. More information can be found at:<\/span><\/p>\r\n<a href=\"https:\/\/ecampusontario.pressbooks.pub\/immunizations\/chapter\/recommended-immunization-schedules-in-canada\/\" target=\"_blank\" rel=\"noopener\">https:\/\/ecampusontario.pressbooks.pub\/immunizations\/chapter\/recommended-immunization-schedules-in-canada\/<\/a>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">If a client is not up-to-date on their vaccines, you should inquire about the reasons why. If a client is <strong>[pb_glossary id=\"1200\"]vaccine hesitant[\/pb_glossary]<\/strong>, explore further in a non-judgmental manner. Respond to their specific concerns with objective facts and refer to vaccines in a positive way. Vaccine hesitancy can be the result of misinformation, so it is important to assess the client\u2019s knowledge and intervene as necessary. Vaccine hesitancy may also be associated with cultural beliefs, and can also be influenced by the client\u2019s relationships with others. More information about vaccine hesitancy can be found at:<\/span><\/p>\r\n<a href=\"https:\/\/ecampusontario.pressbooks.pub\/immunizations\/part\/chapter-5-how-to-respond-to-individuals-with-vaccine-hesitancy\/\" target=\"_blank\" rel=\"noopener\">https:\/\/ecampusontario.pressbooks.pub\/immunizations\/part\/chapter-5-how-to-respond-to-individuals-with-vaccine-hesitancy\/<\/a>\r\n<h2 style=\"text-align: left\"><span style=\"color: #000000\"><strong>Smoking and Vaping<\/strong><\/span><\/h2>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>First-hand, second-hand, <\/strong>and<strong> third-hand<\/strong> <strong>smoke<\/strong> are major risk factors that negatively affect the respiratory system. The chemicals in smoke cause inflammation of the blood vessels, and contribute to plaque buildup and narrowing of the blood vessels. Prenatal exposure and exposure to smoke as a child has particularly harmful effects. In addition to the risks of respiratory diseases (e.g., asthma), these children are also predisposed to hypoxia and conditioning the brain to nicotine.<\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">More recently, <strong>vaping<\/strong> has become common among adolescents and young adults as well as people trying to quit smoking cigarettes. Vaping involves the inhalation of heated aerosols from a vaping device (e.g., electronic cigarettes, vape pens); the aerosols frequently contain nicotine (Miech et al., 2019). Although vaping aerosols may contain less chemicals than cigarettes, there are still many toxins in vaping that can cause lung damage among other health problems (Park et al., 2021).<\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Probing questions related to smoking and vaping include:<\/span><\/p>\r\n\r\n<ul style=\"text-align: left\">\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Do you smoke cigarettes or any tobacco-related products? Do you vape? If the answer is affirmative, ask probing questions: how much do you smoke (how many packs a day)? How many years? Can you tell me about the reasons that you began smoking? (if they vape, you can ask the same questions, but refer to the word they use).<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">If you do not currently smoke, have you ever smoked? If the answer is affirmative, ask similar probing questions, including why the client quit.<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">If relevant: Have you ever tried quitting? If the answer is affirmative, ask probing questions: What made you want to quit? How long did you quit for? Did you use any strategies to help you quit?<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">If relevant: Have you ever thought of quitting? If the answer is negative, respond in a non-judgmental way: \u201cIf you ever want to discuss quitting let me know; there are many resources to help you.\u201d<\/span><\/li>\r\n<\/ul>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Client interest in quitting smoking\/vaping and collaborative intervention are both important for a successful outcome. The intervention must be tailored to the client. Many options are available: counselling, cognitive-behavioural therapy, support groups, pharmacology treatments (e.g., nicotine replacement therapy), smartphone applications, and short text message services. Sometimes even a brief discussion about the risks and a recommendation to quit smoking or vaping is sufficient.<\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">You should consider both relational and structural health promotion approaches related to smoking and vaping. For example, a client\u2019s success in cessation can be affected by their intimate and physically close relationships with family, friends, and work colleagues. Another issue to consider is that access to smoking or vaping cessation resources can be costly and are not necessarily covered by provinces and territories. Many primary care clinics offer group support and counselling at no charge, so it can be helpful to encourage clients to access these resources. You may also advocate for healthy social policy around smoking and vaping cessation and support and participate in the development of educational campaigns and resources about how smoking affects health.<\/span><\/p>\r\n\r\n<h2 style=\"text-align: left\"><span style=\"color: #000000\"><strong>Indoor and Outdoor Pollution<\/strong><\/span><\/h2>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Indoor<\/strong> and <strong>outdoor air pollution<\/strong> can affect respiratory health and exacerbate respiratory conditions. They may include motor vehicle emissions, living close to a highway, radon or asbestos in the home, chemicals such as glue, paint, asbestos, and other household or workplace products, and air quality\/smog\/ozone.<\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Probing questions related to pollution include:<\/span><\/p>\r\n\r\n<ul style=\"text-align: left\">\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Tell me about any indoor and outdoor air pollution you are exposed to?<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Do you have any concerns about how indoor or outdoor pollution is affecting your health?<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Have you noticed that your breathing is affected in any specific indoor or outdoor spaces or on hot days? (Air pollutants and humidity associated with hot weather can aggravate breathing problems).<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Do you wear a mask when using chemicals?<\/span><\/li>\r\n<\/ul>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Any client concerns about exposure to pollutants should be addressed. Some clients need education about safe storage and use of chemicals such as household cleaning products, and keeping windows closed and avoiding exercise on days when the outdoor air quality is low. You might recommend hard-surfaced floors or rugs, because carpets can trap pollutants.<\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Nurses play an important role in the underlying structures that influence healthy environments and pollution. Because the environment has such important effects on health and wellbeing, the Canadian Nurses Association (2017) has developed a position statement about Nurses and Environmental Health. In addition to intervening with actions focused on individual behaviours, nurses can be involved in larger structural approaches involving education campaigns, healthy social policy, and scientific research related to the environment.<\/span><\/p>\r\n\r\n<h2 style=\"text-align: left\"><span style=\"color: #000000\"><strong>Diet<\/strong><\/span><\/h2>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">A healthy diet is important for respiratory health because nutrients and hydration are the fuel the lungs need to breathe and function. Water is a main component of the lungs, and water is essential for the delivery of oxygen throughout the body. Normal fluid losses occur with respiration, and <strong>[pb_glossary id=\"1202\"]hyperpnea[\/pb_glossary]<\/strong> increases this fluid loss, so adequate hydration is essential to effective respiratory functioning. A healthy diet is also important to help maintain an ideal body weight. When a person is obese, the lungs work harder to breathe deep because of the excess weight pushing against the thorax.<\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Probing questions related to diet include:<\/span><\/p>\r\n\r\n<ul style=\"text-align: left\">\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Tell me about your usual diet?<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">What have you eaten in the last 24 hours? Is that your usual diet?<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">How much fluids do you typically drink in a day? What fluids do you drink (e.g., water, caffeinated beverages, alcohol)?<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Do you live in an area where fresh food and drinking water is difficult to access?<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Do you have enough money to buy healthy food?<\/span><\/li>\r\n<\/ul>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">You may assess a client\u2019s familiarity with Health Canada\u2019s Food Guide (Government of Canada 2021)\u00a0and discuss how they might draw upon it to guide their food choices:<\/span> <a href=\"https:\/\/food-guide.canada.ca\/en\/\" target=\"_blank\" rel=\"noopener\">https:\/\/food-guide.canada.ca\/en\/<\/a>. <span style=\"color: #000000\">Be aware that this new guide still has a Eurocentric element to it; you should collaborate with the client about its relevance in the context of their cultural food practices. A snapshot of the guide is now available in dozens of languages:<\/span> <a href=\"https:\/\/www.canada.ca\/en\/health-canada\/services\/canada-food-guide\/resources\/snapshot\/languages.html\" target=\"_blank\" rel=\"noopener\">https:\/\/www.canada.ca\/en\/health-canada\/services\/canada-food-guide\/resources\/snapshot\/languages.html<\/a>. <span style=\"color: #000000\">Many resources have also been developed related to healthy eating and food safety for Indigenous People:<\/span><\/p>\r\n<a href=\"https:\/\/www.sac-isc.gc.ca\/eng\/1581522106156\/1581522147811\" target=\"_blank\" rel=\"noopener\">https:\/\/www.sac-isc.gc.ca\/eng\/1581522106156\/1581522147811<\/a>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Some key elements to consider are:<\/span><\/p>\r\n\r\n<ul style=\"text-align: left\">\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Water should be the drink of choice: hydration can help keep mucus thin.<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">High intake of fruit and vegetable.<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Canada\u2019s Food Guide recommends a dinner plate with half vegetables\/fruit, one-quarter protein, and one-quarter whole grains.<\/span><\/li>\r\n<\/ul>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Some respiratory-related conditions require specific diets. For example, clients with cystic fibrosis often require increased caloric intake to maintain a healthy weight and enzymes to support the pancreas. In clients with COPD, it is important to also maintain a healthy weight and ensure nutrients such as Vitamin D, C, and E (Berthon &amp; Wood, 2015).\u00a0<\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">From a structural health promotion approach, consider a client\u2019s access and financial ability to purchase healthy food. These are elements of food security, and the rising cost of food globally has made it difficult to ensure everyone is food secure. In many remote regions of Canada\u2019s North, access to nutritious food is limited in terms of availability, and even when available, the costs are excessive.<\/span><\/p>\r\n\r\n<h2 style=\"text-align: left\"><span style=\"color: #000000\"><strong>Activity<\/strong><\/span><\/h2>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">A sedentary lifestyle that involves limited activity\/exercise is a risk factor that contributes to respiratory conditions and the overall health of the lungs. Exercise, including aerobic and strength-training, strengthens the lungs and the respiratory muscles, making the lungs more efficient at transporting oxygen.<\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Guidelines vary based on age and health, but individuals should generally participate in about 30 to 60 minutes of aerobic activity five to seven times per week.<\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Probing questions related to activity include:<\/span><\/p>\r\n\r\n<ul>\r\n \t<li style=\"font-weight: 400;text-align: left\"><span style=\"color: #000000\">Do you have any concerns about your level of activity or exercise?<\/span><\/li>\r\n \t<li style=\"font-weight: 400;text-align: left\"><span style=\"color: #000000\">Tell me about your daily pattern of activity? What activities are you involved in?<\/span><\/li>\r\n \t<li style=\"font-weight: 400;text-align: left\"><span style=\"color: #000000\">What exercise do you engage in? How long do you engage in this type of exercise? How many days of the week do you participate in exercise? If the client plays sports, ask about their use of protective equipment, if relevant.<\/span><\/li>\r\n<\/ul>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Collaborate with the client to create an activity\/exercise care plan that is specific to their needs and goals.\u00a0Start at a realistic and attainable level, depending on the client\u2019s physical capabilities and energy level, and then begin to increase the time and duration of the physical activity.\u00a0Many interventions are available to support clients to achieve their activity goals: community walking groups, fitness apps, and joining a local gym or group activity. The participACTION website is a helpful resource related to activity guidelines:<\/span> <a href=\"https:\/\/www.participaction.com\/en-ca\" target=\"_blank\" rel=\"noopener\">https:\/\/www.participaction.com\/en-ca<\/a>. <span style=\"color: #000000\">Consider activity interventions from a structural health promotion approach, considering the financial costs associated with many of these resources.<\/span><\/p>\r\n\r\n<h2 style=\"text-align: left\"><span style=\"color: #000000\"><strong>Stress and Distressing Emotions<\/strong><\/span><\/h2>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Stress<\/strong> and<strong> distressing emotions<\/strong> are subjective and can affect a person physically, mentally, socially, and financially.<\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Stress and other negative emotions affect the respiratory system. Stressful states such as anxiety and anger stimulate the sympathetic nervous system and stimulate the body to breathe faster. This can exacerbate existing respiratory conditions such as asthma.<\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Probing questions related to stress and negative emotions include:<\/span><\/p>\r\n\r\n<ul style=\"text-align: left\">\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Tell me about any stress that affects your breathing? Have you had anxiety or panic attacks affect your breathing? If the client\u2019s answer is affirmative to either question, probe further with questions such as:<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Tell me more?<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">How does it affect your breathing?<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">How often do you experience this?<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">What do you do when you experience this?<\/span><\/li>\r\n<\/ul>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">When considering interventions for a client, consider their daily patterns of living and any disruptions to these patterns, which can be stressful.<\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Various strategies can help reduce stress, including:<\/span><\/p>\r\n\r\n<ul style=\"text-align: left\">\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Engaging in regular physical activity.<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Getting adequate sleep.<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Spending time with family and friends.<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Taking time for personal interests and hobbies.<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Practicing relaxation techniques such as meditation, deep breathing exercises, and tai chi.<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Using pursed lip breathing techniques: this involves taking a slow deep breath in through the nose for two counts and then pursing the lips while breathing out for four counts. It helps with stress and also increases oxygenation and reduces carbon dioxide.<\/span><\/li>\r\n<\/ul>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Use relational and structural health promotion perspectives to further assess a client\u2019s stress and how best to act. Stress does not exist in a vacuum: how it is experienced, perceived, and managed is affected by relationships with others. All clients occasionally experience stress, but structural aspects influence how a client may be more at risk for stress. For example, racism is a major determinant that leads to highly stressful experiences, so use of an anti-racist approach to stress and stress management will help you understand how the client is influenced and how best to support them. Other determinants of health related to socioeconomic status can influence\u00a0 access to resources to cope with stress. When collaborating with clients to develop stress management techniques, you must be aware of these broader structural influences.<\/span><\/p>\r\n\r\n<h2 style=\"text-align: left\"><span style=\"color: #000000\">Activity: Check Your Understanding<\/span><\/h2>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">[h5p id=\"23\"]<\/span><\/p>\r\n\r\n<h2 style=\"text-align: left\"><span style=\"color: #000000\"><strong>References<\/strong><\/span><\/h2>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Berthon, B., &amp; Wood, L. (2015). Nutrition and respiratory health feature review. <em>Nutrients<\/em>, <em>7<\/em>(3), 1618-1643. <a href=\"https:\/\/doi.org\/10.3390\/nu7031618\" target=\"_blank\" rel=\"noopener\">https:\/\/doi.org\/10.3390\/nu7031618<\/a><\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Canadian Nurses Association (2017). Nurses and environmental health.<\/span> <a href=\"https:\/\/www.cna-aiic.ca\/~\/media\/cna\/page-content\/pdf-en\/nurses-and-environmental-health-position-statement.pdf\">https:\/\/www.cna-aiic.ca\/~\/media\/cna\/page-content\/pdf-en\/nurses-and-environmental-health-position-statement.pdf<\/a><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Government of Canada (2021). Canada\u2019s food guide. <\/span><a href=\"https:\/\/food-guide.canada.ca\/en\/\">https:\/\/food-guide.canada.ca\/en\/<\/a><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Miech, R., Johnston, L., O'Malley, P., &amp; Bachman, J. (2019). Adolescent vaping and nicotine use in 2017-2019 - US national estimates. <em>New England Journal of Medicine<\/em>, <em>380<\/em>(2), 192-193. <a href=\"https:\/\/doi.org\/10.1056\/NEJMc1814130\" target=\"_blank\" rel=\"noopener\">https:\/\/doi.org\/10.1056\/NEJMc1814130<\/a>\u00a0<\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Park, J., Alexander, L., &amp; Christiani, D. (2021). Vaping and lung inflammation and injury. <em>The Annual Review of Physiology<\/em>, <em>84<\/em>(18). <a href=\"https:\/\/doi.org\/10.1146\/annurev-physiol-061121-040014\" target=\"_blank\" rel=\"noopener\">https:\/\/doi.org\/10.1146\/annurev-physiol-061121-040014<\/a><\/span><\/p>\r\n&nbsp;\r\n\r\n&nbsp;\r\n\r\n&nbsp;","rendered":"<p style=\"text-align: left\"><span style=\"color: #000000\">Health promotion and disease prevention are important components of a healthy respiratory system. To determine appropriate interventions, you should carefully consider all of the collected data, both subjective and objective. As part of subjective data collection, you should inquire about risk factors, social determinants, and other considerations.<\/span><\/p>\n<p><span style=\"color: #000000\"><span style=\"font-size: 1em\">The inquiry part is integrated throughout the assessment. Many of the probing questions may be asked when doing the subjective assessment. However, some of the questions will be formulated based on your critical reflection of data collected during the subjective and objective assessment. It is this data that will inform your clinical judgment and the health promotion needed for a specific patient.<\/span><\/span><\/p>\n<h2 style=\"text-align: left\"><span style=\"color: #000000\"><strong>Handwashing and Immunization: Self-Care Behaviours\u00a0<\/strong><\/span><\/h2>\n<p style=\"text-align: left\"><span style=\"color: #000000\">Handwashing and immunization are two important factors that affect respiratory health. Regular handwashing is important in healthcare and work settings, when returning home, prior to making and eating food, and before and after elimination.<\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">Probing questions related to handwashing and immunization include:<\/span><\/p>\n<ul style=\"text-align: left\">\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Tell me about when you wash your hands?<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">What is involved in washing your hands? (You may need to probe further: What are the steps involved? How long do you do it for?)<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Are you up to date on your vaccines?<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">When was your last vaccine? What was it for? (You may need to probe about specific vaccines such as influenza [flu], pneumonia, and COVID-19.)<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Have you had tuberculosis testing and when was your last chest x-ray? (You should ask about the results, if relevant). Asking these questions is important part of screening.<\/span><\/li>\n<\/ul>\n<p style=\"text-align: left\"><span style=\"color: #000000\">You may need to provide education about proper handwashing practices: when and how. Tell the client that it is important to wash hands frequently, but always when leaving a building, returning home, before and after meals, and before and after using the washroom. Tell them to wet their hands with water, lather with soap for 20 seconds, rinse and dry their hands, and then turn off the tap with their elbow or a paper towel. Consider how to make it fun with children: you could tell them to sing a song that lasts 20 seconds (e.g., Happy Birthday).<\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">With regard to vaccines, consider the recommended schedule based on age and region. In Canada, vaccine schedules are determined by provinces and territories. More information can be found at:<\/span><\/p>\n<p><a href=\"https:\/\/ecampusontario.pressbooks.pub\/immunizations\/chapter\/recommended-immunization-schedules-in-canada\/\" target=\"_blank\" rel=\"noopener\">https:\/\/ecampusontario.pressbooks.pub\/immunizations\/chapter\/recommended-immunization-schedules-in-canada\/<\/a><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">If a client is not up-to-date on their vaccines, you should inquire about the reasons why. If a client is <strong><button class=\"glossary-term\" aria-describedby=\"357-1200\">vaccine hesitant<\/button><\/strong>, explore further in a non-judgmental manner. Respond to their specific concerns with objective facts and refer to vaccines in a positive way. Vaccine hesitancy can be the result of misinformation, so it is important to assess the client\u2019s knowledge and intervene as necessary. Vaccine hesitancy may also be associated with cultural beliefs, and can also be influenced by the client\u2019s relationships with others. More information about vaccine hesitancy can be found at:<\/span><\/p>\n<p><a href=\"https:\/\/ecampusontario.pressbooks.pub\/immunizations\/part\/chapter-5-how-to-respond-to-individuals-with-vaccine-hesitancy\/\" target=\"_blank\" rel=\"noopener\">https:\/\/ecampusontario.pressbooks.pub\/immunizations\/part\/chapter-5-how-to-respond-to-individuals-with-vaccine-hesitancy\/<\/a><\/p>\n<h2 style=\"text-align: left\"><span style=\"color: #000000\"><strong>Smoking and Vaping<\/strong><\/span><\/h2>\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>First-hand, second-hand, <\/strong>and<strong> third-hand<\/strong> <strong>smoke<\/strong> are major risk factors that negatively affect the respiratory system. The chemicals in smoke cause inflammation of the blood vessels, and contribute to plaque buildup and narrowing of the blood vessels. Prenatal exposure and exposure to smoke as a child has particularly harmful effects. In addition to the risks of respiratory diseases (e.g., asthma), these children are also predisposed to hypoxia and conditioning the brain to nicotine.<\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">More recently, <strong>vaping<\/strong> has become common among adolescents and young adults as well as people trying to quit smoking cigarettes. Vaping involves the inhalation of heated aerosols from a vaping device (e.g., electronic cigarettes, vape pens); the aerosols frequently contain nicotine (Miech et al., 2019). Although vaping aerosols may contain less chemicals than cigarettes, there are still many toxins in vaping that can cause lung damage among other health problems (Park et al., 2021).<\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">Probing questions related to smoking and vaping include:<\/span><\/p>\n<ul style=\"text-align: left\">\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Do you smoke cigarettes or any tobacco-related products? Do you vape? If the answer is affirmative, ask probing questions: how much do you smoke (how many packs a day)? How many years? Can you tell me about the reasons that you began smoking? (if they vape, you can ask the same questions, but refer to the word they use).<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">If you do not currently smoke, have you ever smoked? If the answer is affirmative, ask similar probing questions, including why the client quit.<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">If relevant: Have you ever tried quitting? If the answer is affirmative, ask probing questions: What made you want to quit? How long did you quit for? Did you use any strategies to help you quit?<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">If relevant: Have you ever thought of quitting? If the answer is negative, respond in a non-judgmental way: \u201cIf you ever want to discuss quitting let me know; there are many resources to help you.\u201d<\/span><\/li>\n<\/ul>\n<p style=\"text-align: left\"><span style=\"color: #000000\">Client interest in quitting smoking\/vaping and collaborative intervention are both important for a successful outcome. The intervention must be tailored to the client. Many options are available: counselling, cognitive-behavioural therapy, support groups, pharmacology treatments (e.g., nicotine replacement therapy), smartphone applications, and short text message services. Sometimes even a brief discussion about the risks and a recommendation to quit smoking or vaping is sufficient.<\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">You should consider both relational and structural health promotion approaches related to smoking and vaping. For example, a client\u2019s success in cessation can be affected by their intimate and physically close relationships with family, friends, and work colleagues. Another issue to consider is that access to smoking or vaping cessation resources can be costly and are not necessarily covered by provinces and territories. Many primary care clinics offer group support and counselling at no charge, so it can be helpful to encourage clients to access these resources. You may also advocate for healthy social policy around smoking and vaping cessation and support and participate in the development of educational campaigns and resources about how smoking affects health.<\/span><\/p>\n<h2 style=\"text-align: left\"><span style=\"color: #000000\"><strong>Indoor and Outdoor Pollution<\/strong><\/span><\/h2>\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Indoor<\/strong> and <strong>outdoor air pollution<\/strong> can affect respiratory health and exacerbate respiratory conditions. They may include motor vehicle emissions, living close to a highway, radon or asbestos in the home, chemicals such as glue, paint, asbestos, and other household or workplace products, and air quality\/smog\/ozone.<\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">Probing questions related to pollution include:<\/span><\/p>\n<ul style=\"text-align: left\">\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Tell me about any indoor and outdoor air pollution you are exposed to?<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Do you have any concerns about how indoor or outdoor pollution is affecting your health?<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Have you noticed that your breathing is affected in any specific indoor or outdoor spaces or on hot days? (Air pollutants and humidity associated with hot weather can aggravate breathing problems).<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Do you wear a mask when using chemicals?<\/span><\/li>\n<\/ul>\n<p style=\"text-align: left\"><span style=\"color: #000000\">Any client concerns about exposure to pollutants should be addressed. Some clients need education about safe storage and use of chemicals such as household cleaning products, and keeping windows closed and avoiding exercise on days when the outdoor air quality is low. You might recommend hard-surfaced floors or rugs, because carpets can trap pollutants.<\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">Nurses play an important role in the underlying structures that influence healthy environments and pollution. Because the environment has such important effects on health and wellbeing, the Canadian Nurses Association (2017) has developed a position statement about Nurses and Environmental Health. In addition to intervening with actions focused on individual behaviours, nurses can be involved in larger structural approaches involving education campaigns, healthy social policy, and scientific research related to the environment.<\/span><\/p>\n<h2 style=\"text-align: left\"><span style=\"color: #000000\"><strong>Diet<\/strong><\/span><\/h2>\n<p style=\"text-align: left\"><span style=\"color: #000000\">A healthy diet is important for respiratory health because nutrients and hydration are the fuel the lungs need to breathe and function. Water is a main component of the lungs, and water is essential for the delivery of oxygen throughout the body. Normal fluid losses occur with respiration, and <strong><button class=\"glossary-term\" aria-describedby=\"357-1202\">hyperpnea<\/button><\/strong> increases this fluid loss, so adequate hydration is essential to effective respiratory functioning. A healthy diet is also important to help maintain an ideal body weight. When a person is obese, the lungs work harder to breathe deep because of the excess weight pushing against the thorax.<\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">Probing questions related to diet include:<\/span><\/p>\n<ul style=\"text-align: left\">\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Tell me about your usual diet?<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">What have you eaten in the last 24 hours? Is that your usual diet?<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">How much fluids do you typically drink in a day? What fluids do you drink (e.g., water, caffeinated beverages, alcohol)?<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Do you live in an area where fresh food and drinking water is difficult to access?<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Do you have enough money to buy healthy food?<\/span><\/li>\n<\/ul>\n<p style=\"text-align: left\"><span style=\"color: #000000\">You may assess a client\u2019s familiarity with Health Canada\u2019s Food Guide (Government of Canada 2021)\u00a0and discuss how they might draw upon it to guide their food choices:<\/span> <a href=\"https:\/\/food-guide.canada.ca\/en\/\" target=\"_blank\" rel=\"noopener\">https:\/\/food-guide.canada.ca\/en\/<\/a>. <span style=\"color: #000000\">Be aware that this new guide still has a Eurocentric element to it; you should collaborate with the client about its relevance in the context of their cultural food practices. A snapshot of the guide is now available in dozens of languages:<\/span> <a href=\"https:\/\/www.canada.ca\/en\/health-canada\/services\/canada-food-guide\/resources\/snapshot\/languages.html\" target=\"_blank\" rel=\"noopener\">https:\/\/www.canada.ca\/en\/health-canada\/services\/canada-food-guide\/resources\/snapshot\/languages.html<\/a>. <span style=\"color: #000000\">Many resources have also been developed related to healthy eating and food safety for Indigenous People:<\/span><\/p>\n<p><a href=\"https:\/\/www.sac-isc.gc.ca\/eng\/1581522106156\/1581522147811\" target=\"_blank\" rel=\"noopener\">https:\/\/www.sac-isc.gc.ca\/eng\/1581522106156\/1581522147811<\/a><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">Some key elements to consider are:<\/span><\/p>\n<ul style=\"text-align: left\">\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Water should be the drink of choice: hydration can help keep mucus thin.<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">High intake of fruit and vegetable.<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Canada\u2019s Food Guide recommends a dinner plate with half vegetables\/fruit, one-quarter protein, and one-quarter whole grains.<\/span><\/li>\n<\/ul>\n<p style=\"text-align: left\"><span style=\"color: #000000\">Some respiratory-related conditions require specific diets. For example, clients with cystic fibrosis often require increased caloric intake to maintain a healthy weight and enzymes to support the pancreas. In clients with COPD, it is important to also maintain a healthy weight and ensure nutrients such as Vitamin D, C, and E (Berthon &amp; Wood, 2015).\u00a0<\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">From a structural health promotion approach, consider a client\u2019s access and financial ability to purchase healthy food. These are elements of food security, and the rising cost of food globally has made it difficult to ensure everyone is food secure. In many remote regions of Canada\u2019s North, access to nutritious food is limited in terms of availability, and even when available, the costs are excessive.<\/span><\/p>\n<h2 style=\"text-align: left\"><span style=\"color: #000000\"><strong>Activity<\/strong><\/span><\/h2>\n<p style=\"text-align: left\"><span style=\"color: #000000\">A sedentary lifestyle that involves limited activity\/exercise is a risk factor that contributes to respiratory conditions and the overall health of the lungs. Exercise, including aerobic and strength-training, strengthens the lungs and the respiratory muscles, making the lungs more efficient at transporting oxygen.<\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">Guidelines vary based on age and health, but individuals should generally participate in about 30 to 60 minutes of aerobic activity five to seven times per week.<\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">Probing questions related to activity include:<\/span><\/p>\n<ul>\n<li style=\"font-weight: 400;text-align: left\"><span style=\"color: #000000\">Do you have any concerns about your level of activity or exercise?<\/span><\/li>\n<li style=\"font-weight: 400;text-align: left\"><span style=\"color: #000000\">Tell me about your daily pattern of activity? What activities are you involved in?<\/span><\/li>\n<li style=\"font-weight: 400;text-align: left\"><span style=\"color: #000000\">What exercise do you engage in? How long do you engage in this type of exercise? How many days of the week do you participate in exercise? If the client plays sports, ask about their use of protective equipment, if relevant.<\/span><\/li>\n<\/ul>\n<p style=\"text-align: left\"><span style=\"color: #000000\">Collaborate with the client to create an activity\/exercise care plan that is specific to their needs and goals.\u00a0Start at a realistic and attainable level, depending on the client\u2019s physical capabilities and energy level, and then begin to increase the time and duration of the physical activity.\u00a0Many interventions are available to support clients to achieve their activity goals: community walking groups, fitness apps, and joining a local gym or group activity. The participACTION website is a helpful resource related to activity guidelines:<\/span> <a href=\"https:\/\/www.participaction.com\/en-ca\" target=\"_blank\" rel=\"noopener\">https:\/\/www.participaction.com\/en-ca<\/a>. <span style=\"color: #000000\">Consider activity interventions from a structural health promotion approach, considering the financial costs associated with many of these resources.<\/span><\/p>\n<h2 style=\"text-align: left\"><span style=\"color: #000000\"><strong>Stress and Distressing Emotions<\/strong><\/span><\/h2>\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Stress<\/strong> and<strong> distressing emotions<\/strong> are subjective and can affect a person physically, mentally, socially, and financially.<\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">Stress and other negative emotions affect the respiratory system. Stressful states such as anxiety and anger stimulate the sympathetic nervous system and stimulate the body to breathe faster. This can exacerbate existing respiratory conditions such as asthma.<\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">Probing questions related to stress and negative emotions include:<\/span><\/p>\n<ul style=\"text-align: left\">\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Tell me about any stress that affects your breathing? Have you had anxiety or panic attacks affect your breathing? If the client\u2019s answer is affirmative to either question, probe further with questions such as:<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Tell me more?<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">How does it affect your breathing?<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">How often do you experience this?<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">What do you do when you experience this?<\/span><\/li>\n<\/ul>\n<p style=\"text-align: left\"><span style=\"color: #000000\">When considering interventions for a client, consider their daily patterns of living and any disruptions to these patterns, which can be stressful.<\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">Various strategies can help reduce stress, including:<\/span><\/p>\n<ul style=\"text-align: left\">\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Engaging in regular physical activity.<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Getting adequate sleep.<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Spending time with family and friends.<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Taking time for personal interests and hobbies.<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Practicing relaxation techniques such as meditation, deep breathing exercises, and tai chi.<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Using pursed lip breathing techniques: this involves taking a slow deep breath in through the nose for two counts and then pursing the lips while breathing out for four counts. It helps with stress and also increases oxygenation and reduces carbon dioxide.<\/span><\/li>\n<\/ul>\n<p style=\"text-align: left\"><span style=\"color: #000000\">Use relational and structural health promotion perspectives to further assess a client\u2019s stress and how best to act. Stress does not exist in a vacuum: how it is experienced, perceived, and managed is affected by relationships with others. All clients occasionally experience stress, but structural aspects influence how a client may be more at risk for stress. For example, racism is a major determinant that leads to highly stressful experiences, so use of an anti-racist approach to stress and stress management will help you understand how the client is influenced and how best to support them. Other determinants of health related to socioeconomic status can influence\u00a0 access to resources to cope with stress. When collaborating with clients to develop stress management techniques, you must be aware of these broader structural influences.<\/span><\/p>\n<h2 style=\"text-align: left\"><span style=\"color: #000000\">Activity: Check Your Understanding<\/span><\/h2>\n<p style=\"text-align: left\"><span style=\"color: #000000\"><\/p>\n<div id=\"h5p-23\">\n<div class=\"h5p-iframe-wrapper\"><iframe id=\"h5p-iframe-23\" class=\"h5p-iframe\" data-content-id=\"23\" style=\"height:1px\" src=\"about:blank\" frameBorder=\"0\" scrolling=\"no\" title=\"Ch 3 - Health Promotion\"><\/iframe><\/div>\n<\/div>\n<p><\/span><\/p>\n<h2 style=\"text-align: left\"><span style=\"color: #000000\"><strong>References<\/strong><\/span><\/h2>\n<p style=\"text-align: left\"><span style=\"color: #000000\">Berthon, B., &amp; Wood, L. (2015). Nutrition and respiratory health feature review. <em>Nutrients<\/em>, <em>7<\/em>(3), 1618-1643. <a href=\"https:\/\/doi.org\/10.3390\/nu7031618\" target=\"_blank\" rel=\"noopener\">https:\/\/doi.org\/10.3390\/nu7031618<\/a><\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">Canadian Nurses Association (2017). Nurses and environmental health.<\/span> <a href=\"https:\/\/www.cna-aiic.ca\/~\/media\/cna\/page-content\/pdf-en\/nurses-and-environmental-health-position-statement.pdf\">https:\/\/www.cna-aiic.ca\/~\/media\/cna\/page-content\/pdf-en\/nurses-and-environmental-health-position-statement.pdf<\/a><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">Government of Canada (2021). Canada\u2019s food guide. <\/span><a href=\"https:\/\/food-guide.canada.ca\/en\/\">https:\/\/food-guide.canada.ca\/en\/<\/a><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">Miech, R., Johnston, L., O&#8217;Malley, P., &amp; Bachman, J. (2019). Adolescent vaping and nicotine use in 2017-2019 &#8211; US national estimates. <em>New England Journal of Medicine<\/em>, <em>380<\/em>(2), 192-193. <a href=\"https:\/\/doi.org\/10.1056\/NEJMc1814130\" target=\"_blank\" rel=\"noopener\">https:\/\/doi.org\/10.1056\/NEJMc1814130<\/a>\u00a0<\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">Park, J., Alexander, L., &amp; Christiani, D. (2021). Vaping and lung inflammation and injury. <em>The Annual Review of Physiology<\/em>, <em>84<\/em>(18). <a href=\"https:\/\/doi.org\/10.1146\/annurev-physiol-061121-040014\" target=\"_blank\" rel=\"noopener\">https:\/\/doi.org\/10.1146\/annurev-physiol-061121-040014<\/a><\/span><\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<div class=\"glossary\"><div class=\"glossary__tooltip\" id=\"357-1200\" hidden><p>is when a person is reluctant or refuses to receive a vaccine.<\/p>\n<\/div><div class=\"glossary__tooltip\" id=\"357-1202\" hidden><p>is rapid and deep breathing.<\/p>\n<\/div><\/div>","protected":false},"author":177,"menu_order":15,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[],"contributor":[],"license":[],"class_list":["post-357","chapter","type-chapter","status-publish","hentry"],"part":25,"_links":{"self":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-json\/pressbooks\/v2\/chapters\/357","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-json\/wp\/v2\/users\/177"}],"version-history":[{"count":28,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-json\/pressbooks\/v2\/chapters\/357\/revisions"}],"predecessor-version":[{"id":1962,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-json\/pressbooks\/v2\/chapters\/357\/revisions\/1962"}],"part":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-json\/pressbooks\/v2\/parts\/25"}],"metadata":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-json\/pressbooks\/v2\/chapters\/357\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-json\/wp\/v2\/media?parent=357"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-json\/pressbooks\/v2\/chapter-type?post=357"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-json\/wp\/v2\/contributor?post=357"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-json\/wp\/v2\/license?post=357"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}