ASSESSING MENTAL STATUS INCLUDING RISK FOR SUBSTANCE ABUSE

Mental disorders
The national institute of Mental Health (NIMH) reports that in 2013, 18.5% of US adults
suffered from some form of mental illness. Here are the 5 definition of Mental Disorder that has
the following features.

A. A behavioral or psychological syndrome or pattern that occurs in an individual.

B. That reflects underlying psychobiologic dysfunction.
C. The consequences of which are clinically significant distress or disability.
D. Must not be merely an expectable response to stressors or culturally sanctioned response
to a particular event.
E. That is not primarily a result of social deviance or conflicts with society.

SUBSTANCE ABUSE
-Harmful or hazardous use of psychoactive substances including alcohol and illicit
drugs
-This abuse can lead to a dependence syndrome, which manifests itself in a cluster of
behavioral, cognitive, and physiologic phenomena that develop after repeated
substance use.

HEALTH ASSESSMENT
Collecting Subjective Data: The Nursing Health History
Assessment of mental status is accomplished by interviewing the client and observing his
or her behaviors. Important verbal and behavioral clues about mental status can be assessed drom
the very outset and throughout the entire duration of your interaction with the client.
CLINICAL TIP:
It is best to validate client responses by asking additional questions, verifying data with
another health care professional or comparing objective with subjective findings before
completing the entire assessment. If the nurse finds out that the clients thought process,
perceptions, or level of orientation are impaired, another means of obtaining necessary subjective
data must be identified.
Before asking questions to determine the client’s mental status, explain the purpose of
this part of the examination. Explain that some questions you ask may sound silly or irrelevant
but they will help to determine how certain thought processes.
 Keep in mind that problems with other body systems may affect mental status. For
example, a client with a lowblood sugar may report anxiety or other mental status changes.

Clients who are experiencing symptoms such as memory loss may fear that they have a
serious condition such as brain tumor. They may also fear a loss control and role
performance.
While interviewing the client, you may encounter a variety of emotions. You may have to
discuss sensitive issues such as sexuality, dying or spirituality. Therefore, there are many
interviewing skills you will need to develop to effectively complete a psychosocial history.

EVIDENCE-BASED HEALTH PROMOTION AND DISEASE PREVENTION

INTRODUCTION

Normal aging has common forms of decline that are often

mistaken for dementia or resemble dementia. These include slower thinking, problem solving,
learning, and recall; decreased attention and concentration; more distractedness; and need for
hints to jog memory. It is important to differentiate dementia from common cognitive changes
that occur with age.

According to Healthy People 2020, dementia is not a disease but a set of symptoms
associated with the loss of cognitive functioning—thinking, remembering, and reasoning—to
such an extent that it interferes with a person's daily life. The cognitive changes occur because
of brain diseases or trauma and can have a rapid or a gradual onset. Memory loss is a common
symptom of dementia, although memory loss by itself does not mean a person has dementia.

Alzheimer disease, the most common cause of dementia of the elderly, results from
gradual destruction of brain nerve cells and a shrinking brain. The Alzheimer's Association
describes three states of Alzheimer disease: Stage 1, preclinical, Stage 2, mild cognitive
impairment, and Stage 3, dementia of Alzheimer disease (Alzheimer's Association, 2015a).

Symptoms resemble general dementia symptoms but in the various stages may include loss
of recent memory, depression, anxiety, personality changes, unpredictable quirks or behaviors,
confusion, aggression, agitation, suspicion, wandering, trouble sleeping, inability to recognize
family members, and problems with language, calculation, and abstract thinking. Inability to
manage a budget is a common symptom. Gradually worsening ability to remember new
information is a key symptom.

General symptoms of dementia include (Alzheimer's Association, 2014):

• Memory loss that disrupts daily life
• Challenges in planning or solving problems
• Difficulty completing familiar tasks at home, at work, or at leisure
SCREENING
 Remembering the location of objects
 Remembering the current day of the week
 Communicating thoughts in a conversation
 Finding a way around a familiar house or building
 Thinking ahead
RISK ASSESSMENT
Assess for the following Risk Factors
 Increasing age especially 65 years of age older
 Genetic predisposition and family history
 Mild cognitive impairment
 Head trauma
 Smoking
 Fewer years of formal education
CLIENT EDUCATION
Teach clients and their families
 Actively participate in healthy behaviors
 Keep a helpline phone number available for questions
 Use alzheimer’s association resources
 Help client engage in healthy aging behaviors.
 Engage client in mentally challenging activities.
 Help client to maintain a heart healthy diet and exercise program.

ASSESSMENT GUIDE
This assessment guide can be used to assess the likelihood of a suicide attempt.
RISK FACTORS:
 Sex
 Age
 Depression
 Previous attempt
 Ethanol abuse
 Organized plan
 No spouse
 Sickness
HEALTHY PEOPLE 2020 GOAL
Reduce substance abuse to protect the health, safety and quality of life for all, especially
children.

Assessment Guide(6-1) for Modified SAD PERSONS Suicide Risk Assessment

Risk Factors:
 Sex
 Age
 Depression
 Previous attempt
 Ethanol abuse
 Rational thinking loss
 Social supports lacking
 Organized plan
 No spouse
 Sickness

Collecting Objective Data: Physical Examination

Sometimes the mental status examination is performed with a complete neurologic
assessment. Many find assessing mental status at the very beginning of the head to toe
examination advantageous, as it provides clues regarding the validity of the subjective
information provided by the client throughout the examination.
A comprehensive mental status examination is lengthy and involves great care on the part
of the examiner to put the client at ease. There are several parts of the examination, which
include;
 Level of consciousness
 Posture
 Gait
 Body movements
 Dress
 Grooming
 Hygiene
 Facial expressions
 Behavior and affect
 Speech
  Mood
 Feelings
 Expressions
 Thought processes
 Perceptions
 Cognitive abilities – include orientation, concentration, recent and remote memory,
abstract reasoning, judgment, visual perception and constructional ability

Preparing the Client

Some of the questions you will be asking when collecting both subjective and objective data may
seem silly or may embarrass the client. With practice, you will learn how to infer this
information by observing the client’s responses to other questions during the examination,
negating the need for direct questioning.
Equipment:
 Pencil and paper
 Glasgow Coma Scale
 PHQ-2 to screen for depression during a routine client interview
 PHQ-9 to further assess for client who indicates depression using the PHQ 2
 Depression Questionnaire
 Columbia Suicide Severity Rating Scale (CSSRS)
 SAD PERSONS Suicide Risk Assessment
 Saint Louis University Mental Status (SLUMS) Assessment
 Confusion Assessment Method (CAM)
 SBIRT (Screening, Brief Intervention, and Referral to Treatment)
 CAGE Questionnaire
 The Alcohol Use Disorders Identification Test (AUDIT)

General Routine Screening Versus Focused Specialty Assessment

The nurse completes all of the general screening for all patients as indicated in the box
below. Much of this assessment can be accomplished when the nurse first meets the client and
observes how the client communicates, interacts, and processes information.
General Routine Screening Focused Specialty Assessment
 Observe the client’s level of consciousness  Use the Glasgow Coma Scale(GCS) for clients
who have experienced a traumatic brain injury
 Observe posture, gait, and body movements  Use the PHQ-9(Maurer, 2012) to further assess a
client who indicates depression using the PHQ
 Observe behavior and affect  Use Quick Inventory of Depressive
Symptomatology (Self-Report) Box 6-2 to
determine whether the client is at risk for

 Ask the client: Do you drink alcohol?
What type, how much, and how often?
 Do you use illicit drugs? Type, how much and
how often?
 Observe dress and grooming
 Observe facial expressions
 Assess speech
 Observe mood, feelings and expressions.
 Observe thought processes and perceptions.
Identify possibly self-injurious or suicidal
tendencies
 Assess orientation
 Assess concentration
 Assess recent and remote memory
depression
 Use the Columbia Suicide Severity Rating Scale
(CSSRS) for clients to assess for suicide risk
 Use the SBIRT( Screening, Brief Intervention, and
Referral to Treatment) (SAMSA-HRSA,2011) tool
to identify, reduce, and prevent problematic use,
abuse, and dependence on alcohol and illicit drugs.
 Use the CAGE Self-Assessment(Ewing, 1984) to
detect alcohol dependence in trauma center
populations
 Use the AUDIT questionnaire to assess alcohol-
related disorders
 Use Geriatric Depression Scale if you suspect
depression in the older client
 Use Assessment Guide 6-1, the SAD PERSONS
Suicide Risk Assessment, to determine the risk
factors
 Assess abstract reasoning
 Use the SLUMS Dementia/Alzheimer’s Test
Examination
 Assess judgment ability
 Assess visual, perceptual and constructional ability
 To distinguish delirium from other types of
cognitive impairment, use the Confusion
Assessment Method (CAM)

PHYSICAL ASSESSMENT
Level of Consciousness and Mental Status
Assessment Procedure Normal Findings Abnormal Findings
Observe the client’s level of Client is alert and oriented to Client is not alert to person, place,
consciousness person, place, time and events. day or time; does not make or
Responds to your questions and maintain eye contact; does not
interacts appropriately. respond appropriately.
If the client does not respond Client is alert and awake, with eyes
appropriately, call the client’s name open and looking at examiner.
and note the response. Client responds appropriately.
Use the Glasgow Coma GCS score of 15 indicates an GCS score of less than 15
Scale(GCS) for clients who have optimal level of consciousness. indicates some impairment in the
experienced a traumatic brain level of consciousness. A score of
injury. 3, the lowest possible score,
indicates deep coma.
Observe posture, gait, and body Client is relaxed, with shoulders Slumped posture may reflect
movements. and back erect when standing or feelings of powerlessness or
sitting. Gait is rhythmic and hopelessness characteristic of

Observe behavior and affect.
Observe dress and grooming.
Observe hygiene.
Observe facial expressions, eye
contact, and affect.
Assess speech.
Observe mood, feelings and
expressions.
Observe thought processes and
perceptions.
COGNITIVE ABILITIES
Assessment Procedure
Assess orientation
coordinated, with arms swinging at depression or organic brain
sides. disease.
Client is cooperative and Incongruent behavior may be
purposeful in his or her interactionsseen in clients who are in denial
with others. Affect is appropriate of problems or illness. Prolonged,
for the client’s situation. euphoric laughing is typical of
mania.
Dress is appropriate for occasion Unusually meticulous grooming
and weather. Dress varies and finicky mannerism may be
considerably from person to person, seen in obsessive-compulsive
depending on individual preference. disorder.
The client is clean and groomed Poor hygiene may be seen in
appropriately for occasion. Stains dementia or other conditions and
on hands and dirty nails may reflect may indicate a self-care deficit.
certain occupations such as
mechanic or gardener.
Client maintains eye contact, Reduced eye contact is seen in
smiles, and frowns appropriately. depression or apathy. Extreme
facial expressions of happiness,
anger, or fright may be seen in
anxious clients.
Speech is in a moderate tone, clear, Slow, repetitive speech is
with moderate pace and culturally characteristic of depression or
appropriate. Parkinson disease. Loud, rapid
speech may occur in manic
phases of bipolar disorder.
Cooperative or friendly, expresses Expression of prolonged negative,
feelings appropriate to situation, gloomy, despairing feelings is
verbalizes positive feelings noted in depression.
regarding and the future, and
expresses positive coping
mechanisms.
Client expresses full, free-flowing Clients who are depressed or feel
thoughts; follows directions hopeless are at higher risk for
accurately; expresses realistic suicide. Clients who have
perceptions; is easy to understand depression early in life have a
and makes sense; does not voice twofold increased risk for
suicidal/homicidal thoughts. dementia.
Normal Findings Abnormal Findings
Client is aware of self, others, time, Reduced degree of orientation
home address, and current location; may be seen with organic brain
oriented to person, place, time and disorders or psychiatric illness
events. such as withdrawal from chronic

Assess concentration.
Assess recent memory.
Assess remote memory.
Assess use of memory to learn new
information.
Assess abstract reasoning.
Assess judgment.
Assess visual, perceptual, and
constructional ability.
Use the SLUMS
Dementia/Alzheimer Test
Examination
Glasgow Coma Scale (GCS)
Client listens and can follow
directions without difficulty.
Recalls recent events without
difficulty.
Client correctly recalls past events.
Clint is able to recall words
correctly after a 5-, a 10-, and 30-
minute period.
Client explains similarities and
differences between objects and
proverbs correctly.
Answers to questions are based on
sound rationale.
Draws the face of a clock fairly
well. Can copy simple figures.
A score between 27 and 30 for
clients with a high school
educations and a score of 20-30 for
clients with less than a high school
education is considered normal.
alcohol use or schizophrenia.
Distraction and inability to focus
on task at hand are noted in
anxiety, fatigue, attention deficit
disorders, and impaired states due
to alcohol or drug intoxication.
Inability to recall recent events is
seen in delirium, dementia,
depression, and anxiety.
Inability to recall past events is
seen in cerebral cortex disorders.
Inability to recall words after a
delayed period is seen in anxiety,
depression, or dementia—
Alzheimer’s is one type of
dementia.
Inability to compare and contrast
objects correctly or interpret
proverbs correctly is seen
schizophrenia, mental retardation,
delirium, and dementia.
Impaired judgment may be seen
in organic brain syndrome,
emotional disturbances, mental
retardation, or schizophrenia.
Inability to draw the face of a
clock o copy simple figures
correctly is seen with mental
retardation, dementia or parietal
lobe dysfunction of the cerebral
cortex.
For clients with a high school
education, a score of 20-27
indicates mild cognitive
impairment and for clients with
less than a high school education,
a score of 14-19 indicates MCI.
For clients with a high school
education, a score of 1-19
indicates dementia and for clients
with less than a high school
education, a score of 1-14
indicates dementia.
 Useful for rating one’s response to stimuli. The client who scores 10 or lower needs
emergency attention. The client with a score of 7 or lower is generally considered to
be in coma.

Score
Eye opening response Spontaneous opening 4
To verbal command 3
To pain 2
No response 1
Most appropriate verbal Oriented 5
response Confused 4
Inappropriate words 3
Incoherent 2
No response 1
Most integral motor Obeys verbal commands 6
response (arm) Localizes pain 5
Withdraws from pain 4
Flexion (decorticate rigidity) 3
Extension (decerebrate rigidity) 2
No response 1

SEVEN WARNING SIGNS OF ALZHEIMER DISEASE

1. Asking the same question over and over again
2. Repeating the same story, word for word, again and again
3. Forgetting how to cook, or how to make repairs, or how to play cards – activities that
were previously done with ease and regularity
4. Losing one’s ability to pay bills or balance one’s checkbook
5. Getting lost in familiar surroundings or misplacing household objects
6. Neglecting to bathe, or wearing the same clothes over and over again, while insisting
that they have taken a bath or that their clothes are still clean
7. Relying on someone else, such as a spouse, to make decisions or answer questions
they previously would have handled themselves

The Confusion Assessment Method (CAM)

1. [Acute Onset] Is there evidence of an acute change in mental status from the patient’s
baseline?
2. A. [If present or abnormal] Did this behavior fluctuate during the interview, that is,
tend to come and go or increase and decrease in severity?
3. [Disorganized thinking] Was the patient’s thinking disorganized or incoherent, such
as rambling or irrelevant conversation, unclear or illogical flow of ideas, or
unpredictable switching from subject to subject?
4. [Altered level of consciousness] Overall, how would you rate this patient’s level of
consciousness? (Alert [normal]; Vigilant [hyper alert, overly sensitive to
environmental stimuli, startled very easily]; Lethargic [drowsy, easily aroused];
Stupor [difficult to aroused]; Coma [unarousable]; Uncertain)
5. [Disorientation] Was the patient Disoriented at any time during the interview, such as
thinking that he or she was somewhere other than the hospital or difficulty
remembering instructions?
6. [Memory impairment] Did the patient demonstrate any memory problems during the
interview, such as inability to remember events in the hospital or difficulty
remembering instructions?
7. [Perceptual disturbances] Did the patient have any evidence of perceptual
disturbances, for example, hallucinations, illusions, or misinterpretations (such as
thinking something was moving when it was not)?
8. A. [Psychomotor retardation] At any time during the interview did the patient have an
unusually increased level of motor activity such as restlessness, picking at bedclothes,
tapping fingers, or making frequent sudden changes of position?
8. B. [Psychomotor retardation]At any time during the interview did the patient have an
unusually decreased level of motor activity such as sluggishness, staring into space,
staying in one position for a long time, or moving very slowly?
9. [Altered sleep-wake cycle] Did the patient have evidence of disturbance of the sleep-
wake cycle, such as excessive daytime sleepiness with insomnia at night?

The Confusion Assessment Method (CAM) Diagnostic Algorithm

Feature 1: Acute Onset or Fluctuating Course
This feature is usually obtained from a family member or nurse and is shown by
positive responses to the following questions: Is there evidence of an acute change in
mental status from the patient’s baseline? Did the (abnormal) behavior fluctuate
during the day, that is, tend to come and go, or increase and decrease in severity?

Feature 2: Inattention
This feature is shown by a positive response to the following questions: Did the
patient have difficulty focusing attention, for example, being easily distractible, or
having difficulty keeping track of what is being said?
Feature 3: Disorganized Thinking
This Feature is shown by a positive response to the following question: was the
patient’s thinking disorganized or incoherent, such as rambling or irrelevant
conversation, unclear or illogical flow of ideas, or unpredictable switching from
subject to subject?
 Feature 4: Altered Level of Consciousness
This feature is shown by any answer other than “Alert” to the following question:
Overall, how would you rate this patient’s level of consciousness? (Alert [normal];
Vigilant [hyperalert, overly sensitive to environmental stimuli, startled very easily];
Lethargic [ drowsy, easily aroused; Stupor [difficult to arouse]; Coma [unarousable])

The diagnosis of delirium by CAM requires the presence of features 1 and 2 and
either 3 or 4.

Summary of Differences Between Dementia and Delirium

Alzheimer Disease (AD) Vascular (Multi-Infarct) Delirium
Dementia
Etiology Early-onset Cardiovascular disease Drug toxicity and
Late-onset sporadic-etiology unknown Cerebrovascular disease interactions; acute disease;
Hypertension trauma; chronic disease
exacerbation
Fluid and electrolyte
disorder
Risk factors Advanced age; genetics Pre-existing CV disease Pre-existing cognitive
impairment
Occurrence 70% of dementia 10-20% dementias 7-61% among hospitalized
people
Onset Slow Often abrupt Rapid , acute onset
Follows a stroke or A harbinger of acute
transient ischemic attack medical illness
Age of onset Early-onset AD: 30s-65 years Most commonly 50-70 Any age, although
Late-onset AD: 65+ years years predominantly in older
Most commonly: 85+ years persons
Gender Males and females equally Predominantly males Males and females equally
Course Chronic, irreversible; progressive, Chronic, irreversible Acute onset:
regular, downhill Fluctuating, stepwise Hypoalert - hypoactive
progression Hyperalert - hyperactive
Mixed hypo - hyper
Duration 2-20 years Variable; years Last 1 day to 1 month
Symptoms Onset insidious: Depends on location of Symptoms are fully
progress Early- mild and subtle infarct and success of reversible with adequate
Middle and late- intensified treatment; death attributed treatment; can progress to
Progression to death (infection or to underlying CV disease chronicity or death if
malnutrition) underlying condition is
ignored
Mood Depression common Labile: mood swings Variable
Speech/languag Speech remains intact until late May have speech deficit; Fluctuating; often cannot
e disease: aphasia depending on concentrate long enough to
 Early-mild anomia; deficits progress
until speech lacks meaning; echoes
and repeats words and sounds; mutism
Physical signs Early- no motor deficits
Middle- apraxia(cannot perform
purposeful movement:
Late Dysarthria (impaired speech)
End stage- loss of all voluntary
activity; positive neurologic signs
Orientation Becomes lost in familiar
places(topographic disorientation)
Has difficulty drawing three
dimensional objects(visual and spatial
disorientation)
Disorientation to time, place, and
person – with disease progression
Memory Loss is an early sign of dementia; loss
of recent memory is soon, followed by
progressive decline in recent and
remote memory
Personality Apathy, indifference, irritability:
Early disease-social behavior intact;
hides cognitive deficits
Advanced disease- disengages from
activity and relationships; suspicious;
paranoid delusions cause by memory
loss; aggressive; catastrophic reactions
Functional Poor judgment in everyday activities;
status, activities has progressive decline in ability to
of daily living handle money, use telephone, use
computer and other electronic devices,
function in home and workplace
Attention span Distractible; short attention span
Psychomotor Wandering, hyperactivity, pacing,
activity restlessness, agitation
Sleep-wake Often impaired; wandering and
cycle agitation at nighttime
Validating and Documenting Findings
 To verify that the data are reliable and accurate
ANALYSIS OF DATA: DIAGNOSTIC REASONING
location of lesion speak
May be somnolent
According to location of Signs and symptoms of
lesion: focal neurologic underlying disease
sign: seizures
Commonly exhibits, motor
deficits
May fluctuate between
lucidity and complete
disorientation to time, place
and person
Impaired recent and remote
memory; may fluctuate
between lucidity and
confusion
Fluctuating; cannot focus
attention to converse;
alarmed by symptoms;
hallucinations; paranoid
Impaired
Highly impaired; cannot
maintain or shift attention
Variable; alternates between
high agitation, hyperactivity,
restlessness, and lethargy
Takes brief naps throughout
day and night
 After collecting subjective and objective data pertaining to the mental status examination,
identify abnormal findings and client strengths using diagnostic reasoning.
Selected Nursing Diagnoses
Health Promotion Diagnoses
 Readiness for enhanced health management related to desire and request to learn
more about health promotion
 Readiness for enhanced coping

Risk Diagnoses
 Risk for self-directed violence related to depression, suicidal tendencies,
developmental crisis, lack of support systems, loss of significant others, poor coping
mechanisms, and behaviors
 Risk for developmental delay related to lack of healthy environmental stimulation and
activities
 Risk for powerlessness related to prolonged disability

Actual Diagnoses
 Anxiety related to awareness of increasing memory loss
 Impaired verbal communication related to international language barrier
 Impaired verbal communication related to hearing loss
 Impaired verbal communication related to inability to clearly express self or
understand others
 Impaired verbal communication related to aphasia, psychological impairment, or
organic brain disorder
 Acute or chronic confusion related o dementia, head injury, stroke, alcohol or drug
abuse
 Impaired memory related to dementia, stroke, head injury, alcohol or drug abuse
 Dressing/ grooming self-care deficit related o confusion and lack of resources/
support from caregivers
 Disturbed thought processes related to alcohol or drug abuse, psychotic disorder, or
organic brain dysfunction
 Social isolation related to inability to relate/communicate effectively with others
 Complicated grieving related to suicide of child and increasing isolation from support
systems

Selected Collaborative Problems

After you group the data, it may become apparent that certain collaborative
problems emerge. Remember that collaborative problems differ from nursing diagnoses
 in that they cannot be prevented by nursing interventions. These problems are worded as
risk for complications (RC), followed by the problem.
 RC: Stroke
 RC: Increased intracranial pressure (ICP)
 RC: Seizures
 RC: Meningitis
 RC: Depression

Medical Problems
After you group the data, it may become apparent that the client has signs and symptoms
that require psychiatric medical diagnosis and treatment.
Abnormal Level of Consciousness
 Lethargy- client open eyes, answers questions, and falls back sleep.
 Obtunded- client opens eyes to loud voice, responds slowly with confusion and seems
unaware of environment.
 Stupor- client awakens to vigorous shake or painful stimuli but returns to unresponsive
sleep
 Coma- client remains unresponsiveness to all stimuli; eyes stay closed.

Sources of Voice and Speech Problems

 Dysphonia- voice volume disorder caused by laryngeal disorders or impairment of
cranial nerve X.
 Cerebellar dysarthria- irregular, uncoordinated speech caused by multiple sclerosis.
 Dysarthria- a defect in muscular control of speech related to lesions of the nervous
system, Parkinson Disease, or cerebellar disease.
 Aphasia- difficulty producing or understanding language, caused by motor lesions in the
dominant cerebral hemisphere.
 Wernicke aphasia- rapid speech that lacks meaning, caused by a lesion in the posterior
superior temporal lobe.
 Broca aphasia- slowed speech with difficult articulation, but fairly clear meaning,
caused by a lesion in the posterior inferior frontal lobe.

ASSESSING CULTURE
 Conceptual Foundations
Albrecht et al. (2013, p.2) noyed that the anthropologists have distinguished among these terms:
Disease- “deviations from a biomedical norm”
Illness- “the lived experience of culturallly constructed categories”
Sickness- “patients’ roles”
Based on the idea that everyone has cultural variations, and the number of variations is
increasing everywhere with the large number of immigrants moving from one country to another,
nurses must understand cultural variation as a basis for even minimally safe and effective care.

Concepts and Terms Related to Culture

Culture
Ø defined as a shared system of values, beliefs, and learned patterns of behavior
Ø the totality of socially transmitted behavioral patters, arts, beliefs, values, customs, lifeways,
and all other product of human work and thought characteristic of a population or people
that guide their worldview and decision making (Purnell, 2013)
Values
Ø learned beliefs about what is held good or bad
Norms
Ø learned behaviors that are perceived to be appropriate or inappropriate
Ethnocentrism
Ø The perception that one’s worldview is the only acceptable truth, and that one’s beliefs,
values, and sanctioned behaviors are superior to all others
Ethnicity
Ø “socially, culturally, and politically constructed group of individuals that holds a common
set of characteristics not shared by others with whom its members come in contact.
Terms and Definitions of Culture
Acculturation- The circumstance when a person Enculturation- A natural conscious and unconscious
gives up the traits of his or her culture of origin as a conditioning process of learning accepted cultural norms,
result of context with another culture, to variable values and roles in the society and achieving competence
degrees. in one’s culture through socialization.
Assimilation- The gradual adoption and Ethnicity- A socially, culturally, and politically
incorporation of characteristics of the prevailing constructed group that holds in common set of
culture. characteristics not shared by others with whom members
Cultural Diversity- The co-existence of a
difference in behavior, traditions and customs
Cultural Imposition- The intrusive application of
the majority group’s cultural view upon individuals
and families.
Cultural Relativism- The belief that the behaviors
and practices of people should be judged only from
the context of their cultural system.
Culture- The totality of socially trasmitted
behavioral patters, arts, beliefs, values, customs,
lifeways, and all other products of human work.
of the group come in contact.
Stereotyping- An oversimplified conception, opinion, or
belief about some respec of an individual or group.
Subculture- A group of people with a culture that
differentiates them from the larger culture pf which they
are a part.
Worldview- The way individuals or groups of people
look at the universe to form basic assumptions and values
about their lives and the world around them.

Cultural Competence
According to Campinha-Bacote (2015), there are five constructs in the cultural competence
process
ü Cultural Awareness
ü Cultural Skill
ü Cultural Knowledge
ü Cultural Encounters
ü Cultural Desire
Race
n not a physical characteristic but a socially constructed concept that has meaning to a
larger group
n originates from societal desire to separate people based on their looks and culture
n a vague, inscientific term referring to a group of genetically related individuals who
share certain physical characteristics

Purposes and Scope of Assessment

u To learn about the client’s beliefs and usual behaviors associated with health and illness,
including beliefs about diseases , caregiving, expected treatments, daily hygiene, food
preferences and rituals, religious beliefs relative to health care
u To compare the client’s beliefs and practices with those of other persons from a similar
cultural background (to avoid stereotyping)
u To assess the client’s health relative to diseases prevalent in the specific cultural group
Cultural beliefs and values to assess include:
Ø Value Orientation
Ø Beliefs about human nature
Ø Beliefs about relationship with nature
Ø Beliefs about purpose of life
Ø Beliefs about health, illness and healing
Ø Belief about what causes disease
Ø Beliefs about who serves in the role of healer or what practices bring about healing
Ø Beliefs about the meaning of suffering and pain

Factors Affecting Approach to Providers

l Ethnicity (of both client and health care provider)
l Generational Status (of both client and health care provider)
l Educational Level
l Religion
l Previous health care experiences
l Occupation and income level
l Beliefs about time and space
l Communication needs/preferences

Communication
All communication is culturally based. Verbal communication can have many variations based
on both language differences and usual tone of voice. Nonverbal communication has the most
often misinterpreted variations. These variations include:
n Space
n Eye contact
n Time
n Eye comtact and Face positioning
n Body Language and Hand Gestures
n Silence

Factors Affecting Disease, Illness, Health State

ü Biomedical Variations
ü Nutrition/Dietary Habits
ü Family roles and organizations, patterns
ü Workforce issues
ü High-risk behaviors
ü Pregnancy and childbirth practices
ü Death rituals
ü Religious and spiritual beliefs and practices
ü Health care practices
ü Health care practitioners
ü Environment
Health Care Beliefs
Cultural beliefs that affect health care involve beliefs about communication (which affect the
culturally competent interview process), beliefs about the appropriate categories of persons to
whom an individual goes to seek health care and beliefs about health and illness.
Cultural Variations of Traditional Healers and Practices
Culture Traditional Healers Preventive and Healing
Practices
Asian Traditions Chinese medical Prevent or rebalance yin/yang,
practitioners, herbalists hot/cold foods and conditions,
wear amulets, acupuncture,
cupping, moxibustion
African Traditions Magico herbalists, Hoodoo Magical and herbal mix of herbs,
(also known as conjurers), or roots, and rituals, talismans or
other traditional healers amulets
known as “Old Lady,”
“granny,” or lay midwife
Native American/ Alaska Medicine men and shamans Respect for nature and avoid evil
Native Traditions spirits, use masks, herbs, sand
painting, amulets
Hispanic Traditions
Western European Traditions
Folk Healers (curandero/a, Hot/cold balance for diet, herbs,
bruja/o, yerbero/a, partera) amulets, prayers to God and
saints amd spiritual reparation for
sins, avoidinf “evil eye” caused
by jealousy and envy
Homeopathic physicians, Maintain physical and emotional
physicians, and other health well-being with proper science-
professionals based modern nutrition, exercise,
cleanliness, belief in and faith in
God

Cause of Illness
Western health care and medicine use the biomedical model as a basis for defining illness and
treatments. This model is based on what science can investigate and conclude and assumes that
all disease or illness has a cause and effect that can be studied. Other beliefs about disease and
illness causation, often based on Asian or indigeneous populations’ beliefs are categorized as
holistic and magicoreligious.

Culture-Bound Syndromes
These are conditions that are perceived to exist in various cultures and occur as a combination of
psychiatric or psychological and physical symptoms. It is important to acknowledge the client’s
belief tbat the symptoms form a disorder.

Culture-Based Treatments
These are often misinterpreted in Western health care settings, as they frequently produce marks
on the skin that are interpreted as evidence of abuse. Some of the more common Asian
treatments are cupping, coining and moxibustion.

Death Rituals
As noted by Purnell (2013), death rituals include views on death and euthanasia along with
rituals for dying, burial and bereavement, and are unlikely to vary from the practices of the
client’s original ethnic group. Practices that affect health care include such customs as ritual
washing of the body, the number of family members present at the death of a family member,
and religious practices required during and after dying.
Pregnancy and Childbearing
Cultural variation concerning pregnancy and childbearing includes “sanctioned amd
unsanctioned fertility practices; views towards pregnancy; and prescriptive, restrictive, and taboo
practices related to pregnancy, birthing and the postpartum period” (Purnell, 2013, p. 32).
Pain
Assessing pain is necessary for each client. However, the experience of pain may vary by
cultural conditioning. Some believe that pain is punishment for wrongdoing; others believe it is
atonement for wrongdoing. The response to pain is based on cultural values.

Blood Products, Transfusions, and Blood Donations

Use of blood products and blood transfusions is accepted by most religions except Jehovah’s
Witnesses. Organ donations and autopsy are not accepted by certain cultural groups, including
Christian Scientist, Orthodox Jews, Greeks, and some Spanish speaking groups.

Diet and Nutrition

Dietary considerations in cultural assessment include the meaning of food to the individual,
common foods eaten and rituals surrounding the eating, the distribution of food throughout a 24-
hour day, religious beliefs about foods, beliefs about foods about food and health promotion, and
nutrotional deficiencies associated with the ethnic group.

Spirituality
It is closely associated with culture and includes religious practices, faith, and a relationship with
God or a higher being and those things that bring meaning to life.

Biologic Variation
Often, biologic variations are grouped under the heading of culture; some aspects of biologic
variation, in fact, affect and are affected by cultural beliefs and behaviors. Genetics and
environment, and their interaction, cause humans to vary biologically.

Body Surface Variation

It can be seen in the following secretions: variation in apocrine and eccrine sweat secretions and
the apocrine secretion of earwax. Sebaceous gland activity and secretion composition do not
show significant variation.
Anatomic Variation
Lower extremity venous valves vary between Caucasians and African Blacks. African Blacks
have been noted to have fewer valves in the external iliac veins but many more valves lower In
leg than do Caucasians.

Developmental Variation
Maturity differences appear to be related to both genetics and environment. Caribbean Black,
African Black, and Indian children are less likely to experience delayed motor development than
Caucasian children, but Pakistani and Bangladesh do not fit into this pattern.

Biochemical Variation and Differential Disease Susceptibility

Drug metabolism differences, lactose intolerance, and malaria-related conditions such as sickle
cell anemia, thalassemia, gkucose 6 phopshate dehydrogenase (G6PD) deficiency, and Duffy
blood group are considered biochemical variations.

Geographical and Ethnic Disease Variation

In general, chronic diseasees predominate in developed countries and infectious diseases
predominate in third-world countries. However, there is some genetic and ethnic variation in
addition to the chronic versus infection pattern.

Skin, Hair, Nails

Fair-skinned people, especially those with light eyes and freckles, are at higher risk for
developing skin cancers , although all people who are exposed to high level of intense sunlight
are at risk. The conditions that are common in darker skin are postinflammatory
hyperpigmentation, vitiligo, pityriasis alba, dry or ashy skin, dermatosis papulosanigra and etc.

Head and Neck

The few cultural considerations that come into play are related to dependence on poorly
maintained automobiles or bicycles, lack of use of protective gear, inadequate and ubsafe
housing, and unsafe celebratory practices.

Eyes
Visual impairment varies across age (greater after 50), gender (more in females), and geography
(more that 90% live in developing countries). In all but highly developed countries, cataract is
the leadinf cause of visual disease followed by glaucoma and age related macular degeneration.

Ears
Hearing loss may result from genetic causes, complications at birth, certain infectious diseases,
chronic ear infections, the use of particular drugs, and exposure to excessive noise and aging.

Mouth, Nose, Sinuses

Oral diseases are prevalent in poorer populations in developed and developing countries. They
include dental caries, periodontal disease, tooth loss, oral mucosal and oropharyngeal lesions and
cancers, HIV related diseases and trauma.

Thorax and Lungs

Lung Cancer is directly related to smoking and to the quantity of cigarettes smoked. The highest
rates for lung cancer in the United States in a study from 2013 (CDC, 2016), are among African
American men, followed by Caucasian, American Indian/Alaska Native, Asian/Pacific Islandee,
and Hispanic men.

Breast and Lymphatic System

The CDC (2016) reported a study of female breast cancer survivors and incidence and
prevalence of breast cancer in the United States, noting results as follows: In 2013, Caucasian
women had the highest rate of developimg breast cancer, followed by African American,
Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native women.

Head and Neck Vessels

The Harvard Health Letter (2015) described rates of hypertension, diabetes, and heart disease
variations among ethnic groups, concluding that many intertwined factors likely contribute to the
higher heart disease rates seen among some groups. Findings include that nearly half of all
African American adults have some form of cardiovascular disease, compared with about one
third of all Caucasian adults, and ever after adjustment for factors related to socioeconomic,
disparities in rates of heart disease and its risk factors persist.

Peripheral Vascular System

Studies of risks for chronic venous disease have remained hard to determine, according to Criqui
et al (2007). However, African American ethnicity seems to confer a protective effect.

Abdomen
Gallbladder disease and gallbladder cancer vary by ethnic group in the United States. Native
Americans and Mexican Americans have higher rates of disease and cancer in this organ (ACS,
2014). The highest incidence of stomach cancer is in Asia, Latin America, and the Carribean,
and the lowest incidence in North America and Africa.

Genitalia, Anus, Rectum

Sexually trasmitted infections (chlamydia, herpes, human papilloma virus [HPV], syphilis,
gonorrhea, and HIV/AIDS) vary across US populations. Ethnic variation is thought to be due to
rates of poverty, income inequality, unemployment, low educational attainment, use of drugs,
and other factors, but essentially to risky sexual behavior.

Muscoskeletal System
Up to 90% of bone mass density peaks around 18 in females and by age 20 in males. Bone mass
in women remains stable until after menopause, when it begins to decrease. Bone mass decreases
in both sexes with age and some specific conditions, including lack of weight-bearing exercise.

Nervous System
Occurence of dementia, including Alzheimer disease, is rising rapidly, especially in developing
countries where the number of elderly is increasing (China, India, other South Asian and Pacific
Island countries). Over 50 % of dementia cases in Caucasians are Alzheimer’s, but the rate in
developing countries and in other ethnic groups has not been well studied.

ASSESSING SPIRITUALTY and RELIGIOUS PRACTICES

Spirituality and religion are important factors in HEALTH and can influence HEALTH
DECISIONS and OUTCOMES.
Lifestyle practices
Religious practices
Dietary beliefs
And many aspects of religion and spirituality affect health.
Religious practices and affiliations around the world vary.
To review some of the cultural variation in religious beliefs, see
https://www.roswellpark.org/sites/default/files/node-files/page/nid940-21946-caring-across-
cultures-web.pdf
The level of religious practice in the United States has declined slightly between 2007 and 2014
(from, 92% to 89%) (Pew Research Center, 2015).
What is religion? What is spirituality?

Terms related to Spirituality

Interconnected but separate ideas (Fig. 12-1, Box 12-1)
Religion is defined as the rituals, practices, and to experiences shared within a group that involve
a search for the sacred (e.g., God, Allah, etc.)
Spirituality is defined as a search for meaning and purpose in life; it seeks to understand life’s
ultimate questions in relation to the sacred.
Thoughts on spirituality and religion may vary immensely from one client to the next.
With growing proportion of the population identifying themselves as “spiritual but not religious,
“ the use of the correct instrument or framework will determine the accuracy of an assessment.

The Relationship between Spirituality, Religion, and Health

Public opinion and health care research support the importance of the relationship of religion,
spirituality, and health.
Wright (2005) call suffering, beliefs, and spirituality analogous to three close cousins.
Suffering, be it psychological or physical, is often associated with illness.
A person’s belief about the cause and meaning of suffering and pain affect the illness.
Spiritual beliefs about the meaning of life affect the course of illness and how a person handles
suffering and pain as well.
Nurses can benefit from understanding this three-part relationship when assessing a client’s
spiritual health.

Impact of Religion and Spirituality of Health

Large number of clients use spiritual resources during times of high stress (e.g., hospitalizations).
Religion and spirituality have been shown to relate a person’s greater sense of well-being being
in the face of chronic disease management and ability to adhere to medical regimens.
These can be powerful coping mechanisms when a person faces end-of-life issues.
Spiritual practices have the potential to encourage greater mental and physical health.
Limited list of spiritual activities includes the following;
 Prayer
 Participation in church services
 Yoga
 Tai chi
 Meditation
 Dietary restrictions
 Pilgrimage
 Confessions
 Reflection
 Forgiveness
 Any other activity that includes search for meaning and purpose in life.
If client reports spiritual activities, these activities should ne encourage if found beneficial to
client’s overall health.
Religious groups view the body as a gift and encourage a lifestyle to mirror belief.
Religious beliefs can express a wide array of values and practices, including rituals, (e.g., birth,
death, illness) and ways of dealing with end-of-life issues that may significantly affect religion-
health relationship.
Table 12-1 provides a general review of the major religions and how their beliefs affect health
care decisions.
A working knowledge of the ideals, beliefs, and practices of the faith followed by the majority in
the nurse’s community provides a useful foundation for spiritual care.
When conducting any type of review of the denominations or faiths in a particular community,
be aware that a client’s spiritual dimension is subjective and may vary greatly among persons,
even persons of the same denomination or faith.
The client’s spiritual experiences or spiritual history are subjective and may be the most relevant
factor that guides conversation and decisions about referral or collaboration.
Particular religious views may also negatively affect health.
Failure to seek timely medical care and withholding standardized medical care based on religious
dogma are usually the most prominent ethical dilemmas faced by health care providers.
Christian scientists frequently rely on prayer alone to heal illnesses, rarely seek mainstream
medical care, have higher rates of mortality than the general population.
Jehovah’s Witnesses refuse blood transfusions due to their beliefs that the body cannot be
sustained by another’s blood and accepting a transfusion will bar the receipt from eternal
salvation.
Religion may lead to depression or anxiety over not meeting group expectations, and certain
spiritual practices or participation in complementary and alternative medical practices may delay
needed medical care.
If a nurse is presented within the situation in which religious or spiritual views have the potential
to compromise adequate nursing care, the situation should be presented to a supervising staff
member immediately.
For complex cases, the situation may also presented to the ethics committee of the institution or
organization to assure that appropriate measures are followed.
Refer to the institutional or organizational handbook for specific instructions regarding
individual cases.

Incorporating Religion and Spirituality into Care

Clients have callled for medical providers to address spiritual issues during client-provider
interactions.
In fact, nursing has a long history of incorporating spirituality in client care.
Florence Nightingale wrote at length about a spiritual dimension that provided an inner strength.
Modern nursing theorist have used spirituality as a major determinant in grand theotis that guide
nursing practice.
North American Nursing Diagnosis Association (NANDA) approved nursing diagnoses have
also been formulated to assist nurses in identifying and addressing client’s spiritual dimension.
These developments underlie a primary idea in Nursing: clients are seen as holistic beings in
body, mind and spirit.
Ways to incorporate religion and spirituality into care;
 Providing a time of silence for the client may encourage spiritual practices such as
meditation or the nurse may gather family members or clergy to participate in a prayer
ritual
 Collaboration and referral with pastoral chaplains or clergy are extremely important when
dealing with religious issues in a health care setting.
Nurses can assess the support many clients, ‘ spiritual needs, some situations are beyond the
scope nursing practice and require some with more experience and knowledge about particular
faith.
For example, a nurse from a Protestant faith faced with a Muslim client who has just been
diagnosed with terminal cancer may not be able to speak to the client’s end-of-life issues and
may require referral to appropriate professional.
In whatever form spirituality is incorporated into client care, the nurse should be respectful, open
and willing to discuss spiritual issues if seen as appropriate.
In the process, the nurse should avoid conveying a judgmental attitude toward client’s spiritual
beliefs and religious or practices.

Self-Understanding of Spirituality
Nurses who are aware of their spirituality are more comfortable discussing potential spiritual
needs of the client.
Introspective reflection on one’s own beliefs and biases about the relationship between
Spirituality and health can be undertaken through Journaling, meditation or discussions with
interested persons.
Ask yourself:
 What are my views on the interactions between spirituality and health?
 How would I respond to someone I spiritual distress or to someone requesting an
intervention relating to spirituality?
 How can I provide spiritual care?
These reflection help to provide a deeper understanding of one’s spiritual dimension and build
confidence for future discussions of Spirituality.
Nurses view spiritual assessment and care as an important part of nursing practice, training levels
vary from institution to institution.
However, nurses can educate themselves to meet this vital need of client.
The nurse who understands the content of a spiritual assessment can use this knowledge also to
increase Self-Understanding.
The reason for spiritual assessment is to better understand the client and the client’s
spiritual perspective related to health.
The nurse must be objective during the assessment.
Therefore the nurse would not need to share her views in open dialogue.
SPIRITUAL ASSESSMENT
Spiritual care cannot be provided without a spiritual assessment.
Culliford (2007) listed a few benefits of spiritual care to the client, which include:
 Support for healthy grieving
 Support for improved self-esteem and confidence
 Assistance with maximum potential in the current circumstances
 Support to improved relationships with self, others and with an Absolute/God.
 Assistance in reviewing a sense of meaning and hope
 Enhancement of the client’s sense of belonging
 Assistance in improving problem solving
 Help with enduring problems that cannot be solved and continuing distress and disability
 And help in finding renewed hope.
Spiritual assessment is similar to other assessments perform on a daily basis.
Gaining relevant information about client’s spirituality helps to identify related nursing
diagnoses and needed interventions, can improve client care.
The flowing questions provide guidance in conducting the interview.

Approach
There is no absolute in the timing of a spiritual assessment.
Spiritual assessment should not be viewed as static but rather as an ongoing conversation
between the nurse and the client.
If the nurse were proceeding through an initial assessment with relevant past medical history, it
would be very appropriate to include general screening questions related to client’s integration of
spirituality into their personal health.
‘Do you consider yourself to be a religious or spiritual person? If so, how is this related to your
health or health care decisions? ‘

Client is the focus.

Objectivity is a key component in a high-qualified spiritual assessment.
Questions probe for beliefs that could affect client care.
Divulged information is utilized to support, encourage, or lead clients in harmonizing their
personal relationship to spirituality and health.
Techniques
Spirituality is multidimensional.
It is also unique to each individual.
The most useful spiritual assessment techniques should begin with general introductory
questions and not be specific to any religious denomination so that the nurse can avoid
assumptions and ascertain the client’s specific spiritual needs.
Essential to taking a spiritual history or providing spiritual care to clients is
 maintaining an environment that fosters hope, joy and creativity, provides a sense that a
client is valued, trusted, respected, and worthy of dignity;
 assures confidentiality and sympathetic listening
 gives assistance with making sense and finding meaning in the illness
 and provide support for developing spirituality in current circumstances.

Non-formal
It is helpful to have a quick reference to guide assessment.
Acronyms related to the assessment of spirituality have been published (Assessment Tool 12-1:
Taking a Spiritual History: SPIRIT Acronym) and can serve as excellent reminders as when
assessing a concept with many attributes.
Techniques such as these are Nonformal, yet have somewhat systematic approaches.
They are nonformal in asking open-ended questions and allowing the client to disclose pertinent
information.

FORMAL
The client’s spirituality and religiosity can also be assessed with formal self-assessment
instrument (Assessment Tool 12-1 “Taking a Spiritual History: SPIRIT Acronym”, Assessment
Tool 12-2 :Self-Assessment: “Daily Spiritual Experiences Scale”, and Assessment Tool 12-3
Self-Assessment: Brief Religious Coping Questionnaire ). Other short mnemonic self-assessment
tools include the HOPE Questions for Spiritual Assessment and the FICA Spiritual History Tool.
While many of these measures are paper-and-pencil self response, they begin a dialogue and
could be employed as important screening tools. Completion of a self response spiritual or
religious assessment instrument in conjunction with other past medical history could uncover
strengths or deficiencies that may have initially gone unnoticed.
 SAMPLE FORMAT
A spiritual assessment differs substantially from a health assessment of an organ system.
Spiritual well-being or distress are entirely subjective and the only objective data concern stress
or depression that may accompany spiritual distress. For the reason, the format for the following
spiritual assessment does not follow the same style as organ system chapters. Both normal and
abnormal findings are included to provide better evidence of spiritual distress present.
The nurse must always approach a client’s spirituality with sensitivity and acceptance (even
if not in agreement with the beliefs expressed) to avoid adding further stress to the client.
The following spiritual assessment does not follow any one assessment tool directly, but a
tool may be incorporated into the assessment or used alone. History of present concern, related
past history, family history, and lifestyle and practices are integrated into the assessment.

GENERAL ROUTINE SCREENING VERSUS FOCUSED SPECIALTY ASSESSMENT

OF SPIRITUALITY AND RELIGIOUS PRACTICES
Nurses need to assess the client’s basic religious and spiritual background. More focused
questions and more advanced spiritual assessment tools are used when appropriate and time
allows for this type of assessment.

VALIDATING AND DOCUMENTING FINDINGS

Validate the subjective and objective data collected during assessment (by asking additional
questions, or comparing objective with subjective findings.) Noticeably, the subjective data will
be the primary source of information during a spiritual assessment, but the objective data can
validate or call into question information presented to the nurse. Document both normal and
abnormal findings.

ANALYSIS OF DATA: DIAGNOSTIC REASONING

A client’s spirituality often affects his or her health. There are numerous capacities in which
this occurs and frequently will go unnoticed without assessment. After collecting subjective and
objective data pertaining to the client’s spiritual assessment, identify abnormal findings and
client strengths using diagnostic reasoning. The, cluster the data to reveal any significant patterns
or abnormalities.
The sections below provide possible conclusions that the nurse may make after assessing a
client’s spirituality.
 SELECTED NURSING DIAGNOSES
The following is a list of selected nursing diagnoses that may be identified when analyzing
data from a spiritual assessment.

Health Promotion Diagnoses

 Readiness for Enhanced Spiritual Well-being

 Readiness for Enhanced Hope

Risk Diagnoses
 Risk for Spiritual Distress
 Risk for Loneliness
 Risk for Social Isolation

Actual Diagnoses
 Spiritual Distress
 Hopelessness
 Moral Distress

SELECTED COLLABORATIVE PROBLEMS

After grouping the data, certain collaborative problems may become apparent. Remember that
collaborative problems are differ from nursing diagnoses in that hey can be prevented or managed
with independent nursing interventions.
The following is a list of collaborative problems that may be identified when assessing
spirituality. These problems are worded as risk for complications (RC), followed by the problems.
 RC: Depression
 RC: Hypertension
 RC: Hypoglycemia
 RC: Opportunistic Infections.
The RC related to spirituality is due to the psychological or physiologic responses of the body
under stress. Stress induced by states such as spiritual distress will create a cascade. Of events
within the body.

MEDICAL PROBLEMS
After grouping the data, it may become apparent that the client has signs and symptoms that
require medical diagnosis and treatment. Referral to a primary care provider is necessary.