NCM 120 Transcultural Nursing
Module 3: Cultural Competence in the Health
History and Physical Examination
3.3.1. Lesson: Cultural Competence in the Health
History and Physical Examination-2
CULTURAL COMPETENCE IN THE HEALTH
HISTORY AND PHYSICAL EXAMINATION
CULTURAL ASSESSMENT
 Cultural Assessment or Culturologic
Assessment – refers to a systematic,
comprehensive examination of individuals,
families, groups and communities regarding
their health-related cultural beliefs, values, and
practices.
 Form the foundation for the client’s plan of care,
providing valuable data for setting mutual goals,
planning care, intervening, and evaluating the
care.
GOAL:
 to determine the nursing and health care needs of
people from diverse cultures and intervene in
ways that are culturally acceptable, congruent,
competent, safe, affordable, accessible, high
quality and based on current research, evidence
and best practices
Cultural Assessment consist of both PROCESS and
CONTENT
 Process – refers to how to approach to the client,
consideration of verbal and nonverbal
communication, and the sequence and order in
which data are gathered.
 Content – consists of the actual data categories in
which information about clients is gathered.
TRANSCULTURAL PERSPECTIVE ON THE
HEALTH HISTORY
PURPOSE OF THE HEALTH HISTORY
 Is to gather subjective data
 Health History provides a comprehensive overview
of a client’s past and present health, and it
examines the manner in which the person interacts
with the environment.
 Health History enables the nurse to assess health
strengths, including cultural beliefs and practices
that might influence the nurse’s ability to provide
culturally competent nursing care.
 History is combined with the objective data from
the physical examination and laboratory results
to form a diagnosis about the health status of a
person.
 Well client – history is used to assess
lifestyle (which includes activity, exercise,
diet and related personal behaviors and
choices that nurses may gather to identify
potential risk factors for disease).
 Ill Client – health history includes a
chronologic record of the health problems.
 Note: Health history is a screening tool for
abnormal symptoms, health problems, and
concerns for both well and ill clients.
 Health History provides valuable information
about the coping strategies and health-related
behaviors and responses used previously by
clients and family members.
A. Biographic Data:
1. Cultural Affiliation
2. Ancestry or Ethnohistory
B. Genetic Data:
 Genetics – is a branch of biology that
studies heredity and the variations of
inherited characteristics
 Genomics- addresses all genes and their
interrelationship to identify their combined
influence on the growth and development of
the organism
 Genome – is an organism’s complete set of
DNA, including all of its genes
 Epigenetics- is the study of how genes are
influenced by forces such as environment,
obesity or medication
C. Genetic Screenings:
 Drug efficacy or sensitivity:
 Pharmacogenomicst -the study of the role of
inherited and acquired genetic variation in
drug response, is an evolving field that
facilitates the identification of biomarkers
that can help health providers optimize drug
selection, dose, and treatment duration as
well as eliminate adverse drug reactions.
 Carrier screening:
 Genetic tests can identify heterozygous
carriers for many recessive diseases such as
cystic fibrosis, sickle cell disease, and Tay–
Sachs disease. A couple may wish to
undergo carrier screening to help make
reproductive decisions, especially in
populations where specific diseases are
relatively common, for example, Tay–Sachs
disease in Ashkenazi Jewish populations and
β-thalassemia in Mediterranean populations
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 Prenatal diagnosis:
o Amniocentesis is usually performed at
16 weeks’ gestation; chorionic villus
sampling (CVS) is carried out at 10 to
12 weeks’ gestation; preimplantation
genetic diagnosis (PGD) is carried out
on early embryos (8 to 12 cells) prior to
implantation; and fetal DNA analysis in
maternal circulation is done at 6 to 8
weeks’ gestation

REVIEW OF MEDICATIONS AND ALLERGIES

 includes all current prescription, over the
counter, and home remedies, including herbs
that a client might purchase or grow in a home
garden.
 During the health history, note the name, dose,
route of administration, schedule, frequency,
purpose, and length of time that each medicine
that has been taken.
 Inquire about vitamins, birth control pills,
aspirin, antacids, herbs, teas, inhalants,
poultices, vaginal and rectal suppositories,
ointments, and any other items taken by the
client for therapeutic purposes.

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HERBAL REMEDIES

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 CULTURAL DIFFERENCES IN RESPONSE TO  Cultural norm – unconscious behavior patterns
DRUGS: that are typical of specific groups

PRESENT HEALTH AND HISTORY OF PRESENT

ILLNESS
 Culture-bound syndromes – refers to more than
200 disorders created by personal, social and
cultural reactions to malfunctioning biological or
psychological processes and can be understood
only within defined contexts of meaning and
social relationships.
 When assessing clients with a culture-bound
syndrome, it is important for the nurse to find
out what the client, family, and other concerned
individuals believe is happening; what prior
efforts for help or cure have been tried; and what
the results or outcomes from the treatment were.
A. Past Health
 Past illnesses are important for multiple
reasons.
 It may have residual effects on the current
state of health or have sequelae that appear
many months or years later
B. Family and Social History
 A comprehensive and accurate family
history highlights those diseases and
disorders for which a client may be at
increased risk.
C. Biocultural Aspects of Disease

REASON FOR SEEKING CARE

 Reason or reasons for Seeking Care
 Refers to a brief statement in the client’s own
words describing why he/she is visiting a health
care provider.
 Previously called “chief Complaint”
 Symptoms – defined as phenomena experienced
by individuals that signify a departure from normal
function, sensation, or appearance and that might
include physical aberrations
 Signs – objective abnormalities that the examiner
can detect on physical examination or through
laboratory testing

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 B. Biocultural Variations in the Assessment of
C. Biocultural Variations in General
D. Review of Systems
 The purpose of the review of systems is
threefold:
1. to evaluate the past and present health
state of each body system,
2. to provide an opportunity for the client
to report symptoms not previously
stated, and
3. to evaluate health promotion practices.
TRANSCULTURAL PERSPECTIVE ON THE
PHYSICAL EXAMINATION
A. Biocultural Variations
 Height
 Body Proportions – Blacks have longer arms
and legs and shorter trunks than Whites,
Native Americans or Asians
 Weight – Black Men weigh less than their
white counterparts
 Vital Signs – Black Men have lower SBP
than their White counterparts from ages 18-
D. Biocultural Variations in Skin
34; but reverses at 35-64
o Incidence of HTN is 2x as high in
African Americans
Pain
 Pain - is defined as an unpleasant sensory
and emotional experience conveyed by the
brain through sensory neurons arising from
actual or potential tissue damage to the
body. Derived from the Greek word for
penalty, pain is often associated with
punishment in Judeo–Christian thought.
 Pain is the most frequent and compelling
reason that people seek health care and is
sometimes referred to as the fifth vital sign.
 Pain is a culture universal that is
experienced by people in all parts of the
world.
 Classifications:
o Acute Pain - a direct, one-to-one
relationship exists between an injury and
pain, and the pain is frequently short-
lived and self-limiting
 Sensation threshold - refers to the lowest
stimulus that results in tingling or warmth.
 Pain threshold refers to the point at which
the individual reports that a stimulus is
painful.
Appearance
a. In assessing general appearance, survey
the person’s entire body.
Note the general health state and any obvious
physical characteristics and readily apparent
biologic features unique to the individual.
b. In assessing the client’s general
appearance, consider four areas:
 PHYSICAL APPEARANCE - includes age,
gender, level of consciousness, facial
features, and skin color
 BODY STRUCTURE - includes stature,
nutrition, symmetry, posture, position, and
overall body build or contour
 MOBILITY - includes gait and range of
motion.
 BEHAVIOR - includes such variables as
facial expression, mood and affect, fluency
of speech, ability to communicate ideas,
appropriateness of word choice, grooming,
and attire or dress.
 Melanin is responsible for the various colors
and tones of skin observed in different
people.
 Melanin protects the skin against harmful
ultraviolet rays—a genetic advantage
accounting for the lower incidence of skin
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 cancer among darkly pigmented Black and
Native American clients
 Mongolian Spots - are irregular areas of
deep blue pigmentation usually located in
the sacral and gluteal areas but sometimes
occurring on the abdomen, thighs, shoulders,
or arms.
 Mongolian spots are a normal variation in
children of African, Asian, or Latin descent.
By adulthood, these spots become lighter
but usually remain visible. Mongolian spots
are present in 90% of Blacks, 80% of Asians
and Native Americans, and 9% of Whites
 Vitiligo - a condition in which the
melanocytes become nonfunctional in some
areas of the skin, is characterized by
unpigmented, patchy, milky white skin
patches that are often symmetric bilaterally.
 Vitiligo affects an estimated 2 to 5 million
Americans. There is no greater prevalence
among dark-skinned individuals, although
the disorder may cause greater psychosocial
stress in these groups because it is more
visible
 Hyperpigmentation - Other areas of the skin
affected by hormones and, in some cases,
differing for people from certain ethnic
backgrounds are the sexual skin areas, such
as the nipples, areola, scrotum, and labia
majora.
o In general, these areas are darker than
other parts of the skin in both adults and
children, especially among African
American and Asian clients.
o When assessing these skin surfaces on
dark-skinned clients, observe carefully
for erythema, rashes, and other
abnormalities because the darker color
might mask their presence.
 Cyanosis - A severe condition indicating a
lack of oxygen in the blood.
o Cyanosis is the most difficult clinical
sign to observe in darkly pigmented
persons.
 Jaundice
o In both light- and dark-skinned clients,
jaundice is best observed in the sclera.
o When examining culturally diverse
individuals, exercise caution to avoid
confusing other forms of pigmentation
with jaundice.
o Many darkly pigmented people, for
example, African Americans, Filipinos,
and others, have heavy deposits of
subconjunctival fat that contain high
levels of carotene in sufficient quantities
to mimic jaundice.
 Pallor
o Assessing for pallor in darkly pigmented
clients can be difficult because the
underlying red tones are absent.
o This is significant because these red
tones are responsible for giving brown
or black skin its luster.
o The brown-skinned individual will
manifest pallor with a more yellowish
brown color, and the black-skinned
person will appear ashen or gray.
o Generalized pallor can be observed in
the mucous membranes, lips, and nail
beds.
 Erythema – is frequently associated with
localized inflammation and is characterized
by increased skin temperature.
o (redness) can also be difficult to assess
in darkly pigmented clients because the
contrast between white and red is more
pronounced than it is when the skin
color is darker.
 Petechiae are best visualized in the areas of
lighter melanization, such as the abdomen,
buttocks, and volar surface of the forearm.
When the skin is black or very dark brown,
petechiae cannot be seen in the skin.
 Ecchymoses caused by systemic disorders
are found in the same locations as petechiae,
although their larger size makes them more
apparent on dark-skinned individuals
o When differentiating petechiae and
ecchymoses from erythema in the
mucous membrane, pressure on the
tissue will momentarily blanch erythema
but not petechiae or ecchymoses.
 Addison’s Disease
o The cortisol deficiency characteristic of
Addison’s disease causes an increase in
melanin production, which turns the skin
a bronze color that resembles sun tan.
The nipples, areola, genitalia, perineum,
and pressure points such as the axillae,
elbow, inner thighs, and buttocks look
bronze. Addison’s disease is very
difficult to recognize in people with
darkly pigmented skin; therefore,
laboratory tests and other clinical
manifestations of the disease should be
used to corroborate the skin changes
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  Uremia
o is the illness accompanying kidney
failure characterized by unexplained
changes in extracellular volume,
inorganic ion concentrations, or lack of
known renal synthetic products. Uremic
illness is due largely to the accumulation
of organic waste products, not all
identified, that are normally cleared by
the kidneys.
o Renal failure causes retained urochrome
pigments in the blood to turn the skin of
a person with uremia gray or orange-
green. In people with darkly pigmented
skin, it may be difficult to visualize the
skin color changes; therefore, skin
manifestations of uremia are often
masked. Laboratory tests and other
clinical findings are needed to
corroborate the observation of skin color
change when assessing a person with
suspected uremia
 Albinism
o refers to a group of inherited conditions.
People with albinism have little or no
pigment in their eyes, skin, or hair.
o They have inherited altered genes that
do not make the usual amounts of the
pigment melanin
o Most children with albinism are born to
parents who have normal hair and eye
color for their ethnic backgrounds.
o Vision problems are associated with all
forms of albinism. People with albinism
always have impaired vision (not
correctable with eyeglasses) and many
have low vision
 Café au lait spots- tan to light brown
irregularly shaped oval patches with well-
defined borders, are caused by increased
melanin pigment in the basal cell layer of
the skin
E. Biocultural Variations in Sweat glands
 The apocrine and eccrine sweat glands are
important for fluid balance and
thermoregulation.
 Eskimos have made an environmental
adaptation whereby they sweat less than
Whites on their trunks and extremities but
more on their faces
 African Americans have lower salt
concentrations in their sweat than Whites do.
F. Biocultural Variation in the Head
 Hair
o Obtaining a baseline hair assessment is
significant in the diagnosis and
treatment of certain disease states
 Eyes
o Persons of Asian background are often
identified by their characteristic
epicanthal eye folds, whereas the
presence of narrowed palpebral fissures
in non-Asian individuals might be
diagnostic of a serious congenital
anomaly known as Down syndrome or
trisomy 21.
 Ears
o Ears come in a variety of sizes and
shapes. Earlobes can be freestanding or
attached to the face.
 Mouth
o Oral hyperpigmentation also shows
variation by race. Usually absent at
birth, hyperpigmentation increases with
age
o Cleft uvula, a condition in which the
uvula is split either completely or
partially, occurs in 18% of some Native
American groups and 10% of Asians
o Leukoedema, a grayish-white benign
lesion occurring on the buccal mucosa,
is present in 68% to 90% of blacks and
43% of whites.
 Teeth
o are often used as indicators of
developmental, hygienic, and nutritional
adequacy, and there are important
biocultural differences
o The size of teeth varies widely, with the
teeth of Whites being the smallest,
followed by Blacks and then Asians and
Native Americans. The largest teeth are
found among Native Alaskans and
Australian Aborigines.
o Larger teeth cause some groups to have
prognathic (protruding) jaws, a
condition that is seen more frequently in
African and Asian Americans
o Agenesis (absence of teeth) varies by
race, with missing third molars
occurring in 18% to 35% of Asians, 9%
to 25% of Whites, and 1% to 11% of
Blacks. Throughout life, whites have
more tooth decay than blacks, which
might be related to a combination of
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 socioeconomic factors and biocultural
variation.
G. Biocultural Variation in the MSK  Cultural Care Preservation Or Maintenance
 The long bones of blacks are significantly  refers to those professional actions and
longer, narrower, and denser than those of decisions that help people of a particular
whites. Bone density measured by race and culture to retain and/or preserve relevant
gender shows that black males have the care values so that they can maintain their
densest bones, accounting for the relatively well-being, recover from illness, or face
lower incidence of osteoporosis and hip handicaps and/or death
fractures in this population. Similarly, Black  Cultural Care Accommodation Or Negotiation
women have lower incidence of these two  refers to professional actions and decisions
conditions when compared with Hispanic that help people of a designated culture to
and White women adapt to or to negotiate with others for
 Bone density in Chinese, Japanese, and beneficial or satisfying health outcomes with
Native Alaskans is below that of Whites professional care providers
(Overfield, 1995).  Cultural Care Repatterning Or Restructuring
 In a study of men aged 65 and older, the  refers to professional actions and decisions
highest prevalence of self-reported that help clients reorder, change, or greatly
nontraumatic fracture was Whites, 17%; modify their lifeways for new, different, and
African Americans, 15%; Hispanics, 14%; beneficial health care patterns while
and Asian Americans, 11%. respecting the clients’ cultural values and
 Low bone mineral density was associated beliefs and yet providing more beneficial or
with higher prevalence of bone fracture in healthier lifeways than before the changes
all groups were co-established with the clients.
 Native Americans and First Nation People
of Canada have anteriorly convex femurs,
whereas Blacks have markedly straight
femurs, and Whites have intermediate
femurs. This characteristic is related to both
genetics and body weight.
 The femurs of thin blacks and whites have
less curvature than average, whereas those
of obese blacks and whites display increased
curvatures. It is possible that the heavier
density of the bones of blacks helps to
protect them from increased curvature
caused by obesity.
 Blacks tend to be wide shouldered and
narrow hipped; Asians tend to be wider in
the hips and narrower in the shoulders.
 Blacks have more skeletal muscle than
White, Hispanic, and Asian counterparts
across the entire age range, even when
adjusting for weight and height.

TRANSCULTURAL PERSPECTIVE IN CLINICAL

DECISION MAKING AND ACTIONS
Leininger suggests three major modalities to guide
nursing decisions and actions for the purpose of
providing culturally congruent care that is beneficial,
satisfying, and meaningful to clients:
 Cultural Care Preservation Or Maintenance,
 Cultural Care Accommodation Or Negotiation,
And
 Cultural Care Repatterning Or Restructuring
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