Cultural Factors
Biological Factors
Provider Culture
Healer Within

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TransCultural Nursing Assessment 


Date ____________ Time ____________   Pt Initials  ________ Age ______    M     F

Medical dx __________________________________________________________________

Communication - language, voice quality, pronunciation, use of silence and nonverbals. 


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__________________


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. 


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 __________________________________________

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. 


Do you have any plans for the future? _________________________________________________________

What do you consider a proper greeting? ______________________________________________________


  Tactile relationships, affectionate & embracing.

Personal space? _________________________________________________________________________

Biological Variations - skin color, body structure, genetic and enzymatic patterns, nutritional preferences and deficiencies. 


What type of food do you prefer? ____________________________________________________________

What type of food to you dislike?_____________________________________________________________

what do you believe promotes health?__________________________________________________________

Family hx of disease? ______________________________________________________________________


Skin color ______________________

Hair type _______________________

Environmental Control - health practices, values, definitions of health and illness. 


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) ?


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. 


Preventive health measures ?   Y   N _________________________________________


Time orientation    Present   Past

Hx of noncompliance, missed appointments?__________________________________________________


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