Assessment Data
Milwaukee is the city of focus for The Final Community Health Paper. The City of Milwaukee is populated woth just under 600,000 people. Milwaukee lies along the shores and bluffs of Lake Michigan, which supplies three rivers: the Menomonee, the Kinnickinnic and the Milwaukee. Milwaukee’s lakefront resembles that of an oceanfront Lake Michigan is too large to see across. Milwaukee's terrain is relatively flat, except for steep bluffs along the lakeshore that begin about one half mile north and four miles south of the downtown.
According to the United States Census Bureau, the city has a total area of 96.9 square miles. 96.1 square miles of it is land and 0.9 miles squared of it is water. Included in this graph is some basic demographic information: General Characteristics | Number | Percent | U.S. | Total population | 596,974 | | | Male | 285,363 | 47.8 | 49.1% | Female | 311,611 | 52.2 | 50.9% | Median age (years) | 30.6 | (X) | 35.3 | Under 5 years | 47,545 | 8.0 | 6.8% | 18 years and over | 425,990 | 71.4 | 74.3% | 65 years and over | 65,123 | 10.9 | 12.4% | | | | | One race | 580,824 | 97.3 | 97.6% | White | 298,379 | 50.0 | 75.1% | Black or African American | 222,933 | 37.3 | 12.3% | American Indian and Alaska Native | 5,212 | 0.9 | 0.9% | Asian | 17,571 | 2.9 | 3.6% | Native Hawaiian and Other Pacific Islander | 301 | 0.1 | 0.1% | Some other race | 36,428 | 6.1 | 5.5% | Two or more races | 16,150 | 2.7 | 2.4% | | | | | Hispanic or Latino (of any race) | 71,646 | 12.0 | 12.5% | | | | | Household population | 580,571 | 97.3 | 97.2% | Group quarters population | 16,403 | 2.7 | 2.8% | | | | | Average household size | 2.50 | (X) | 2.59 | Average family size | 3.25 | (X) | 3.14 | | | | | Total housing units | 249,225 | | | Occupied housing units | 232,188 | 93.2 | 91.0% | Owner-occupied housing units | 105,235 | 45.3 | 66.2% | Renter-occupied housing units | 126,953 | 54.7 | 33.8% | Vacant housing units | 17,037 | 6.8 | 9.0% | | | | | Social Characteristics show more | Number | Percent | U.S. | Population 25 years and over | 353,305 | | | High school graduate or higher | 264,358 | 74.8 | 80.4% | Bachelor's degree or higher | 64,742 | 18.3 | 24.4% | Civilian veterans (civilian population 18 years and over) | 45,613 | 10.7 | 12.7% | Disability status (population 5 years and over) | 120,800 | 22.2 | 19.3% | Foreign born | 46,122 | 7.7 | 11.1% | Male, Now married, except separated (population 15 years and over) | 86,729 | 41.2 | 56.7% | Female, Now married, except separated (population 15 years and over) | 86,202 | 35.7 | 52.1% | Speak a language other than English at home (population 5 years and over) | 87,288 | 15.9 | 17.9% | | | | | Economic Characteristics - show more >> | Number | Percent | U.S. | In labor force (population 16 years and over) | 283,052 | 63.9 | 63.9% | Mean travel time to work in minutes (workers 16 years and over) | 22.5 | (X) | 25.5 | Median household income in 1999 (dollars) | 32,216 | (X) | 41,994 | Median family income in 1999 (dollars) | 37,879 | (X) | 50,046 | Per capita income in 1999 (dollars) | 16,181 | (X) | 21,587 | Families below poverty level | 23,687 | 17.4 | 9.2% | Individuals below poverty level | 123,664 | 21.3 | 12.4% | | | | | Housing Characteristics - show more >> | Number | Percent | U.S. | Single-family owner-occupied homes | 82,308 | | | Median value (dollars) | 80,400 | (X) | 119,600 | Median of selected monthly owner costs | (X) | (X) | | With a mortgage (dollars) | 863 | (X) | 1,088 | Not mortgaged (dollars) | 322 | (X) | 295 |

(X) Not applicable.
Source: U.S. Census Bureau, Summary File 1 (SF 1) and Summary File 3 (SF 3) |

Beyond the basic demographic information, causes of mortality and morbidity are vital statistics for the community health nurse. Here are some main causes for morbidity and mortality in the Milwaukee Area:
Mortality- According to Wisconsin State Department of Health 2006 Statistics
1. Heart Disease- 1,973 Deaths
2. Cancer (Respiratory, Colorectal, and Female Breast) – 1,756 Deaths
3. Cerebral Vascular Disease - 464 Deaths
4. Lower Respiratory Disease - 381 Deaths
5. Pneumonia and Flu – 153 Deaths
Morbidity
1. Communicable Diseases- including Hepatitis B,A,C, and Salmonellosis 2. Sexually Transmitted Diseases- Chlamydia, Genital Herpes, Gonorrhea.
Compared to the United States as a whole:
Number of deaths for leading causes of death: * Heart disease: 631,636 * Cancer: 559,888 * Stroke (cerebrovascular diseases): 137,119 * Chronic lower respiratory diseases: 124,583 * Accidents (unintentional injuries): 121,599 * Diabetes: 72,449 * Alzheimer's disease: 72,432 * Influenza and Pneumonia: 56,326 * Nephritis, nephrotic syndrome, and nephrosis: 45,344 * Septicemia: 34,234
Source: Deaths: Final Data for 2006, Tables B, D, 7, 30- http://www.cdc.gov/nchs/FASTATS/deaths.htm.
As can be seen the Milwaukee statistical mortality is consistent with the rest of the nation.

Windshield Survey
Community Vitality
Visible people in the community are mostly in transportation, transit to and from work. Milwaukee is a city caters to automobile transportation. Putting focus on the neighborhood of Downtown Milwaukee Zip code 53203, population of 335, the age range is mostly from age 18-60. This is a young working professional group. There are very few elders and children. The most common race/ethnicity is White/Caucasian. The general appearance those in the neighborhood(walking to work) are those dressed in professional attire, those dressed in athletic attire, running, many are running towards the lakefront who are Marquette University Students. I noticed at the bus stops in this zip code are mostly African Americans. At each bus stop at 5pm 9 out 10 of those waiting for the bus were smoking. There is a noticeable homeless population in this area. Since the Midwest Express Center is in this neighborhood, there was a large number of out of town visitors here for a business conference. This area contains are majority of the more popular alcohol establishments, thus there were a large number of people from the business conference under the influence of alcohol the night of this windshield survey. There were only a few small children seen in this survey and no pregnant women.
Indicators of Social and Economic Conditions
The general condition of the homes in this area (apartments or condos) is very good. Many are rehabilitated buildings outfitted for residence. A unique feature for this area is that many of the buildings have both commercial and residential zoning within the same building. There are a large number of vacant businesses in this area. The Grand Avenue Mall is at less than half capacity with open and running stores and businesses.
Health Resources
The closest hospital to this area is Sinai Samaritan Medical Center, which is one zip code away. I noticed several billboards and advertisements at the local shopping center for Sinai. There is also the Aids Resource Center of Milwaukee located in this neighborhood, and The Downtown YMCA.
Environmental Conditions Related to Health
The roads were asphalt and concrete with scattered potholes. A main thoroughfare, Wisconsin Avenue is under repair and partially closed. Since the housing in this area in good general condition, this area looks to be free of sanitary issues at the surface. The Milwaukee River, however, flow directly through this neighborhood. I canoed this river as a part of my survey and noticed there are quite a few pipes for sewage overflow into the river.
Social Functioning
As previously mentioned, this is the center for nightlife, restaurants and bars in the area, thus it is a meeting point for a large part of the city’s social functioning. In my windshield survey I noticed four catholic churches. I did not see any neighborhood watch stickers. I did see people in blue polo shirts who are special visitor guides for Downtown Milwaukee.
Attitude toward Health and Health Care
Prevention and Wellness - The Local Downtown YMCA in this Zip Code, provides a health promotion approach to fitness, promoting healthy lifestyles though education, fitness programs for all levels and affordable memberships for all incomes. Each year the Downtown YMCA holds a health fair in The Grand Avenue Mall.
Problem Identification Based on the mortality data about the city of Milwaukee, mixed with the finding of my windshield survey, three problems I consider important to address are: 1. Heart disease prevention- This disease is the number cause of mortality, not just for Milwaukee, but the nation. I would to focus on health promotion modifiable risk factors for this disease. 2. Lung Cancer- The modifiable risk factors here are similar to the lifestyle choices of modifiable risk factors for heart disease. Also with Milwaukee being a city that is based on automobile transportation, this also contributes to incidence of Lung Cancer. 3. Unemployment Epidemic- This is a growing problem as evidenced in my windshield by the many vacant businesses.
Because of the high mortality of heart disease and considerable modifiable risk factors:
Smoking, cholesterol and diet control, hypertension, diabetic control, healthy weight maintenance, healthy stress management, exercise, and control of alcohol consumption.
Aurora Health Care offers Primary Services such as
Abdominal aortic aneurysm graft
Ablation
Angioplasty
Atherectomy
Brachytherapy
Cardioversion
Cardiac stents
Implantable cardioverter defibrillator
Pacemaker implant
Pericardiocentesis
Patent Foramen Ovale (PFO) Closure
Surgical treatments
Bypass surgery and off-pump bypass surgery * Heart transplant * Heart valve replacement * Microwave ablation * Robotic surgery * TMLR (transmyocardial laser revascularization) * Ventricular assist device
Primary Prevention: Heart wellness classes, diet choices classes, Aurora Wellness retail stores.
Secondary Prevention:
Heart scans, Blood pressure screenings, Cholesterol Screening
Tertiary Prevention:
Cardiac rehabilitation, Guided imagery, Support groups

Vulnerable Population Because heart disease is the highest mortality and the modifiable risk factors have been previously identified, the vulnerable population for my community is those who live a sedentary lifestyle. My windshield survey showed me many alcohol serving establishments in this area and only one fitness facility. Because Milwaukee’s downtown is a social meeting point, it attract more visitors that residents. At the same Milwaukee allows smoking indoors at all restaurants, night clubs and bars. With this in mind, some of the risk factors for this population are heart disease, lung cancer, obesity, type 2 diabetes, alcoholic liver cirrhosis, hepato renal disease, cerebral vascular disease, etc. Thus, two pressing issues for this population are increasing exercise and decreasing smoking (quitting) and alcohol consumption.
The Healthy People leading indicators, physical activity, overweight and obesity, tobacco use, substance abuse, responsible sexual behavior, mental health, injury and violence, environmental quality, immunization, access to health care (www.healthypeople.gov/lhi) are very much in line with this vulnerable population, specifically, physical activity, overweight and obesity, tobacco use, and substance (alcohol) abuse.
Community Health Nurse
The nurse I interviewed is a visiting home health nurse, who works in my chosen community. She described to me her daily work life in the form some basic tips for practice:
1. Have a good sense of humor, no career will be enjoyable if you can’t laugh at yourself.
2. Be open minded. The patient’s home is not a controlled environment like a hospital or doctor office. Though one must follow agency's policies, safety rules and perform procedures correctly, one must also be respectful of the patient’s home. Diversity is one of the wonderful aspects of home care, you learn how other people really live. Learn to appreciate different cultures.
3. Learn to modify. This is necessary for survival.
4. Be flexible. The planned out day will change, guaranteed. One must be flexible to do home health.
5. Be prepared. She keeps a trunk full of medical supplies
6. Be organized. She always has something to write with, a charged computer and cell phone.
7. Safety is very important. Home health nursing in Milwaukee takes her into some very unsafe neighborhoods.
8. Don’t get behind on charting. Home health requires a huge amount of charting. Though the VNA is computerized, it is not as efficient as the hospital.

9. Keep skills up to date. She takes continuing education classes on-line, she attends seminars, read articles, and evidence based practice research. Knowledge is power. (Personal Communication, July 24th 2009)
Much of the population she visits for the purpose of congestive heart failure management. This is tertiary prevention in that she utilizes medication management, diet management, and increasing the patient’s activity.
Major concerns she has for the population she serves is the lack of health promotion. Much of what she sees in her day to day visits are people with preventable health problems. Much of their problems could have been avoided with lifestyle change

Community Health Applied to Practice My practice is in a Surgical Intensive Care Unit. Based on the Health Interventions Wheel from Community/Public Health Nursing by Mcewen and Nies 2007, my practice mostly falls into the Individual, Community, and Systems Focused section of the wheel.
Collaboration/Delegated Functions: In the ICU, we have patients with complex disease processes. As the coordinator of the patient’s care, we collaborate with a variety of other disciplines to find answers to questions, problem solve, trouble shoot, develop a long term plan, etc. Some of the everyday collaborator disciplines for ICU Nursing include: Respiratory Therapy, Speech, Social Work, Wound Care, Vascular Access, Radiology, and Dialysis
Consultation: This an important part caring for an ICU patient. I must be aware of my available consults for different physician specialties. While my patient may be managed by the surgeon, the patient may have complex needs the surgeon will most likely not be available or have the expertise to address. It is vitally important for me to have a very clear and complete picture of my patient’s complex issues so that I can make sure they are addressed by the addressed by the appropriate specialties.
Counseling: We sometimes have critical patients in my unit for extended periods of time. This can be emotional very difficult for the patient and their families. Currently we have a patient on our unit who has stayed for 6 months. His wife has not gone home in this time. She stays in his small ICU room on chair, day in, day out. We have provided to her resources for counseling and support groups. I have also taken the role of counselor myself and allowed her time to express her frustration. Since she has not visited her hometown of Manitowoc, I visited it myself and took pictures of some of the local landmarks for her obtunded husband to have a sense of familiarity with.
Health Teaching: While many of our patients are critical, many also at a level they are excellent candidates for various teaching prior to discharge or transfer. This teaching can be from Diabetic teaching and reinforcement, incentive spirometry, wound care, and exercise.
Care Management: This is an important piece of the total picture for an ICU patient. In caring for a complex patient, we need to use case management to understand and plan out the pathway for a particular patient within realistic parameters. For example, a patient 3 months post Liver Transplant who has been intubated 5 times and then received a tracheostomy and has a complex wound infection that is slowly resolving. We would be working with a case manager to find the best fit for long term high acuity care.
Evaluation and Summary Looking at the city of Milwaukee and my Zip code, 53203, It seems to me our concerns are towards health promotion and economic stimulation. With so many closed businesses and people in employment contingency, health promotion takes less priority. On the other hand, the 53203 area has a progressive mind set. The local YMCA is still full, new members and health seekers are valuing their health and looking for ways to improve their quality of life. Working in an ICU that specializes in Kidney and Liver Transplant. much of our patient population are victims of their long term lifestyle choices. Since I live in a community that thrives economically on people consuming alcohol, I am often thinking about the gap between a person with hepatorenal syndrome and someone who is partaking in stimulating the economy of my zip code.

References
McEwen, M. A & McEwen, M. (2007). Health: A Community View. Community/Public Health Nursing. (p. 15). Missouri: Saunders, Elsevier. www.aurora.org. Retrieved. July 22, 2009 http://www.cdc.gov/nchs/FASTATS/deaths.htm. Retrieved, July 22, 2009 http://dhs.wisconsin.gov/localdata/pdf/06pubhlth/milwaukee06.pdf. Retrieved, July 22, 2009 http://milwaukeedowntown.com/categories/8-downtowndata/documents/3-downtown-data. Retrieved, July 22, 2009