3.2 Risk Assessment and Social Determinants

Quick Answer: The current ANCC FNP-BC Assessment skill names genetic, behavioral, lifestyle, and cultural risk. The October 30, 2026 TCO adds sexual risk and social determinants of health. Teach the superset now. A three-generation pedigree, pack-years, AUDIT-C, the 5 P's, intimate-partner-violence and firearm questions, and housing/food/transport screens change who gets tested and how soon — the same way a BRCA-pattern pedigree changes breast imaging.

Risk assessment is not a lifestyle lecture stapled to the end of the visit. It is how you revise the probability of disease before you order the test, choose an interval, or write a regimen the patient cannot execute.

Genetic risk: pedigree before the panel

Start with a three-generation family history: children, siblings, parents, aunts and uncles, grandparents; age at onset; type of cancer or vascular event; and ancestry when it changes carrier risk. A pedigree drawn in two minutes is more useful than 'family history positive' in the EHR checkbox.

Cancer red flags that should trigger genetics referral, not 'watch and screen as average risk':

• Breast cancer at 50 or younger, triple-negative breast cancer, male breast cancer, or ovarian cancer at any age
• Two or more primary breast cancers, or breast plus ovarian cancer in the same lineage
• Colorectal or endometrial cancer under 50, or multiple Lynch-spectrum cancers (colon, endometrium, ovary, stomach, urothelial) among close relatives
• A known familial pathogenic variant
• Many colorectal adenomas suggesting a polyposis syndrome

Do not order a consumer ancestry kit and call it counseling. Refer to genetics or a high-risk clinic when criteria are met. Discuss cascade testing only after a true pathogenic result in the family.

Hereditary hemochromatosis clues: unexplained fatigue, arthralgia, bronze or gray hyperpigmentation, abnormal transaminases, diabetes, or cardiomyopathy plus northern European ancestry or a first-degree relative with iron overload. Transferrin saturation and ferritin are the assessment labs; HFE testing follows a compatible iron pattern, and first-degree relatives need a plan.

Thrombophilia clues: unprovoked VTE at a young age, VTE in unusual sites, a strong family history of VTE, or recurrent unexplained pregnancy loss. The assessment is the history that justifies hematology referral — not reflex Factor V Leiden on every traveler with a sprain. A 28-year-old with unprovoked pulmonary embolism is a genetics/hematology problem. A 72-year-old with postoperative DVT after hip replacement is not.

Behavioral risk

Tobacco. Record pack-years (packs per day × years) and current versus former versus never, plus vaping or e-cigarette use and secondhand exposure. Pack-years drive lung-cancer screening eligibility (USPSTF: ages 50–80, 20 or more pack-years, currently smoke or quit within 15 years). 'Smokes socially' is not a pack-year history.

Alcohol. AUDIT-C is three questions: frequency, quantity, and binge. Common primary-care cutoffs are 4 or more in men and 3 or more in women for a positive screen that requires a fuller assessment (full AUDIT, withdrawal risk, liver disease, driving, pregnancy). Do not wait for jaundice to ask the three questions.

Other drugs. Ask about cannabis, opioids (including leftover pills), stimulants, and nonprescribed benzodiazepines in a specific, nonjudgmental way. 'Any street drugs?' misses the parent taking a teenager's stimulant.

Suicide. For youth, the ASQ (Ask Suicide-Screening Questions) is a brief validated screen. C-SSRS, used conceptually, distinguishes wish to die, plan, intent, and recent behavior. A positive screen is a same-visit safety assessment, not a PHQ-9 footnote you will 'mention next time.'

Intimate partner violence. HITS (Hurt, Insult, Threaten, Scream) and the Abuse Assessment Screen (AAS) are brief tools. Screen privately — never with the partner translating. A positive screen requires a safety plan and knowledge of mandatory reporting for children, vulnerable adults, and, in some states, injuries from weapons.

Firearms. Ask whether there is a gun in the home, whether it is locked, and who can reach it when depression, dementia, IPV, or adolescents are in the household. This is lethality assessment, not a political debate. A firearm multiplies the fatality of a suicide or IPV crisis.

Lifestyle risk

Assess diet pattern (sugar-sweetened beverages, fruit and vegetable intake, overlap with food insecurity), activity in minutes per week of moderate work (being on your feet at a register is not aerobic training), sleep (duration, shift work, apnea clues), and occupational exposures (solvents, silica or asbestos, night shift, heavy lifting, needlesticks, agricultural pesticides, ultraviolet radiation). A 45-year-old roofer is a skin-cancer and heat-illness assessment. A night-shift nurse with an A1c of 5.8% has a different diabetes-prevention conversation than a sedentary office worker with the same number.

Sexual risk — the 5 P's (teach for the October 30, 2026 TCO)

Use the 5 P's whenever sexual health is relevant, not only in an STI clinic:

1. Partners — number, sex of partners, new partner, monogamy, partner concurrency
2. Practices — oral, vaginal, anal; this chooses which anatomic sites to test
3. Protection from STIs — condoms, PrEP eligibility, vaccines (HPV, hepatitis B, and mpox when indicated)
4. Past STI history — prior syphilis, gonorrhea, chlamydia, HIV, hepatitis, pelvic inflammatory disease
5. Pregnancy intention — trying, ambivalent, or avoiding; method and consistency of contraception

A 22-year-old with pharyngitis and new male partners who says 'I am not sexually active for pregnancy' still needs you to think about pharyngeal gonorrhea and chlamydia. Practices, not identity labels, drive the test menu.

Cultural risk and the explanatory model

Culture is not a checkbox for preferred language. Assess:

• Explanatory model: What do you call this problem? What do you think caused it? What do you fear? What treatment do you expect?
• Language: preferred language and whether a qualified interpreter is required. Family members are not interpreters for IPV, sexual, or suicide questions.
• Health literacy: teach-back on the plan, not 'do you understand?' A high-school diploma does not equal the ability to titrate insulin.
• Religious and cultural practices that change the exam or the medicine: fasting (Ramadan, Yom Kippur), refusal of porcine gelatin capsules, modesty needs for a genital exam, prayer times versus dosing, use of traditional healers, and beliefs about blood products.

Ignoring the explanatory model produces a chart that says nonadherence when the real failure was the assessment.

SDOH — required thinking for the October 30, 2026 TCO

Social determinants of health are the conditions in which people live that often drive outcomes more than the prescription you wrote. At minimum assess housing, food, transportation, insurance or cost, neighborhood safety, and utilities or digital access.

PRAPARE (Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences) and the CMS Accountable Health Communities (AHCM) screen are the conceptual tools. You do not need every item memorized. You do need to treat a positive food or housing screen as a clinical finding that may justify social-work referral, a 14-day rather than 90-day follow-up, and a simpler regimen.

How risk changes pretest probability and screening interval

Risk is how you decide who gets the test and how soon.

• A 42-year-old at average risk follows the usual breast-imaging start age. A 42-year-old whose mother had ovarian cancer at 49 needs genetics and a high-risk breast pathway now.
• A never-smoker at 55 is not in the low-dose CT window. A 55-year-old with 25 pack-years who quit 8 years ago may meet USPSTF lung-cancer criteria.
• Colonoscopy at 45 is average-risk timing. A first-degree relative with colon cancer at 48 commonly moves the first colonoscopy to 10 years before that age or age 40, whichever comes first.
• A sexually active 16-year-old with a new partner and no condoms needs site-specific STI testing regardless of symptoms. An abstinent 16-year-old does not need the same panel.
• An older adult with food insecurity and a PHQ-9 of 16 has a higher pretest for poor diabetes control. Check access before you escalate insulin.

Integrated vignette

A 41-year-old woman presents to establish care. She works nights in a warehouse, vapes daily, and drinks a six-pack most weekends. Her mother died of ovarian cancer at 49; a maternal aunt had breast cancer at 44. She has a new male partner and does not use condoms; she is unsure whether she wants pregnancy this year. She skipped two prior appointments because she lost her ride, and she uses a food pantry monthly. Blood pressure is 148/92.

This single visit contains genetic red flags (refer genetics; do not wait for an age-50 average-risk mammogram), behavioral risk (vaping; an AUDIT-C-positive drinking pattern), sexual risk (5 P's → site-appropriate STI testing, contraception or PrEP discussion, pregnancy intention), occupational and lifestyle risk (night shift, warehouse), SDOH (transport, food), and a blood pressure that will not improve if you only print a DASH handout she cannot afford to follow. The 'right' next imaging interval is the smallest piece of the risk assessment.