TransCultural Nursing Assessment
Date ____________ Time ____________ Pt
Initials ________ Age ______
Medical dx __________________________________________________________________
Communication - language,
voice quality, pronunciation, use of silence and nonverbals.
Can you speak English?
Can you read English?
Are you able to read lips?
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
Eye contact -
Direct Peripheral gaze or no eye contact
preferred during interactions.
Use of interpreter Family
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
Social Orientation - cultural,
ethnicity, family role function, work leisure, church, and friends.
Country of birth? ______________________ Years in this
(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
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_________________
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
Time - use of measures,
definitions, social and work time, time orientation -- past, present,
Preventive health measures ? Y
Time orientation Present
Hx of noncompliance, missed appointments?__________________________________________________
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