Cultural Factors Biological Factors Provider Culture Healer Within Assessment |           |

TransCultural Nursing Assessment    Date ____________ Time ____________   Pt Initials  ________ Age ______    M     F Medical dx __________________________________________________________________ Communication - language, voice quality, pronunciation, use of silence and nonverbals.  Subjective- Can you speak English?      YES      NO         Can you read English?        YES      NO Are you able to read lips?   YES     NO Native Language? ____________________ Do you speak or read any other language? _______________________________ How do you want to be addressed?    Mr.   Mrs.   Ms    First Name   Nick Name__________________ Objective- How would you characterize the nonverbal communication style? ______________________________________ _______________________________________________________________________________________ Eye contact -    Direct     Peripheral gaze or no eye contact preferred during interactions. Use of interpreter   Family    Friend    Professional    Other    None  Verbally loud and expressive.   Quiet, reserved   use of silence Meaning of common signs - O.K., got ya nose, index finger summons,  V sign, thumbs up _______________________________________________________________________________________ Determine any familial colloquialisms used by  individuals or families that may impact on assessment, treatment or other interventions. _______________________________________________________________________________________ _______________________________________________________________________________________ Social Orientation - cultural,  ethnicity, family role function, work leisure, church, and friends.  Subjective- Country of birth? ______________________ Years in this country ___________  (If an immigrant or a refugee, how long has the patient lived in  this country? -You are not questioning legal status.) What setting did you grow up in --  urban   suburban   rural  What is your ethnic identity? _________________________________________   Who are the major  support people:  0family members  0friends  0other _________________________________ Who are the dominant family members? _________________________________________________________ Who makes  major decisions for the family? ______________________________________________________  Occupation in native country_________________  Present Occupation____________________ Education? ______________________________________________________________________________ Is religion important to you? _________________________________________________________________ What is your religion affiliation? __________ would you like a Chaplain visit?  Y   N Any cultural/religious practices/restrictions?  If yes describe __________________________________________ Objective- Interaction with family\significant other - describe __________________________________________________ _______________________________________________________________________________________ Age and life cycle factors must be considered in interactions with individuals and families ( e.g. high value placed on the decision of elders, the role of eldest male or female in families, or roles and expectation of children within the family). _______________________________________________________ ______________________________________________________________________________________ Religious icons on person or in room?__________________________________________________________ Space - comfort in conversation, proximity to others, body movement, perception of space.  Subjective- Do you have any plans for the future? _________________________________________________________ What do you consider a proper greeting? ______________________________________________________ Objective-   Tactile relationships, affectionate & embracing.   Non-contact  Personal space? _________________________________________________________________________ Biological Variations - skin color, body structure, genetic and enzymatic patterns, nutritional preferences and deficiencies.  Subjective- What type of food do you prefer? ____________________________________________________________ What type of food to you dislike?_____________________________________________________________ what do you believe promotes health?__________________________________________________________ Family hx of disease? ______________________________________________________________________ Objective- Skin color ______________________ Hair type _______________________ Environmental Control - health practices, values, definitions of health and illness.  Subjective- What do you think caused your problem? ______________________________________________________ Do you have an explanation for why it started when it did?__________________________________________ What does your sickness do to you; how does it work?____________________________________________ How severe is your sickness? How long do you expect it to last? ____________________________________ What problems has your sickness caused you?__________________________________________________ What do you fear about your sickness?________________________________________________________ What kind of treatment do you think you should receive?___________________________________________ What are the most important results you hope to receive from this treatment?____________________________ ______________________________________________________________________________________ What are the health and illness beliefs and practices of the family? ____________________________________ ______________________________________________________________________________________ What are the most important things you do to keep healthy?_________________________________________ ______________________________________________________________________________________ Any concerns about health and illness? ________________________________________________________ What types of healing practices do you engage in (hot tea and lemon for cold, copper bracelet for arthritis, magnets) ? ______________________________________________________________________________________ Ojective-  Described patients appearance and surroundings _________________________________________________ What diseases/disorders are endemic to the culture or country of origin? _______________________________ What are the customs and beliefs concerning major life events? ______________________________________ Time - use of measures, definitions, social and work time, time orientation -- past, present, and future.  Subjective- Preventive health measures ?   Y   N _________________________________________ Objective- Time orientation    Present   Past Hx of noncompliance, missed appointments?__________________________________________________ Copyright © 1997-2008 culturediversity.org.  All Rights Reserved. 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