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?__________________________________________________