Professional Documents
Culture Documents
The following color bars are used consistently for each section within a chapter to help locate specific information.
STRUCTU R E A N D F U N C T I O N
Anatomy and physiology by body system
SUB J E C T I V E DATA
Health history through questions (examiner asks) and explanation (rationale)
OBJ E C T I V E DATA
Core of the examination part of each body system chapter with skills, expected findings, and common variations for healthy
people, as well as selected abnormal findings and health promotion
D O CUMENTATION A N D C R I T I C A L T H I N K I N G
Clinical case studies with sample documentation for subjective, objective, and assessment data
ABNO R M A L F I N D I N G S
Tables of art and photographs of pathologic disorders and conditions; abnormal findings for advanced practice or special cir-
cumstances where appropriate
CONTENTS
http://evolve.elsevier.com/Jarvis/
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Physical
Examination
& Health
Assessment
Seventh Edition
7
Original Illustrations by Pat Thomas, CMI, FAMI
East Troy, Wisconsin
NANDA International Nursing Diagnoses: Definitions and Classifications 2012-2014; Herdman T.H. (ED);
copyright © 2012, 1994-2012 NANDA International; used by arrangement with John Wiley & Sons, Limited. In
order to make safe and effective judgments using NANDA-I nursing diagnoses it is essential that nurses refer to
the definitions and defining characteristics of the diagnoses listed in the work.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
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This book and the individual contributions contained in it are protected under copyright by the Publisher
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This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such information
or methods they should be mindful of their own safety and the safety of others, including parties for
whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration,
and contraindications. It is the responsibility of practitioners, relying on their own experience and
knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each
individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
any liability for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.
Printed in Canada
Carolyn Jarvis received her BSN cum laude from the Univer- Dr. Jarvis has maintained a clinical practice in advanced
sity of Iowa, her MSN from Loyola University (Chicago), and practice roles—first as a cardiovascular clinical specialist in
her PhD from the University of Illinois at Chicago, with a various critical care settings and as a certified family nurse
research interest in the physiologic effect of alcohol on the practitioner in primary care. She is currently a Professor at
cardiovascular system. She has taught physical assessment Illinois Wesleyan University; is a nurse practitioner in Bloom-
and critical care nursing at Rush University (Chicago), the ington, Illinois; and is licensed as an advanced practice nurse
University of Missouri (Columbia), and the University of in the state of Illinois. During the last 8 years, her enthusiasm
Illinois (Urbana), and she has taught physical assessment, has focused on using Spanish language skills to provide health
pharmacology, and pathophysiology at Illinois Wesleyan Uni- care in rural Guatemala and at the Community Health Care
versity (Bloomington). Clinic in Bloomington. Dr. Jarvis has been instrumental in
Dr. Jarvis is a recipient of the University of Missouri’s developing a synchronous teaching program for Illinois Wes-
Superior Teaching Award; has taught physical assessment to leyan students both in Barcelona, Spain, and at the home
thousands of baccalaureate students, graduate students, and campus.
nursing professionals; has held 150 continuing education
seminars; and is the author of numerous articles and text-
book contributions.
v
CONTRIBUTORS
Susan Caplan, PhD, MSN, APRN-BC Sarah Jarvis, BSN, RN, DNPc
The contributor for Chapter 2, Cultural Competence, and the The co-contributor for Chapter 10, Pain Assessment: The
culture content in Chapter 7, Domestic and Family Violence Fifth Vital Sign, is a hematology and oncology nurse at the
Assessments, is an Assistant Professor and Family Nurse Prac- University of Michigan Health System in Ann Arbor, Michi-
titioner Specialty Director at Rutgers University. Dr. Caplan gan. She has 7 years of experience working with cancer-
completed her PhD in Nursing at Yale University. She has related pain management. She is also a doctoral student at
published and lectured extensively about cultural compe- Wayne State University in Detroit, Michigan.
tency in the health care professions.
Joyce K. Keithley, DNSc, RN, FAAN
Martha Driessnack, PhD, PNP-BC The contributor for Chapter 11, Nutritional Assessment, is a
The contributor for the Health Promotion boxes is an Associ- Professor at Rush University College of Nursing and Rush
ate Professor in the School of Nursing at Oregon Health & University Medical Center in Chicago. Because she has
Science University. She received her PhD from Oregon Health worked in both clinical and instructional settings, she is an
& Science University and completed a postdoctoral research experienced and well-known practitioner, teacher, researcher,
fellowship in clinical genetics. Her primary focus is as an and author in the area of clinical nutrition.
advocate for including the voices of children in health-related
decisions that affect them. Kelsey Merl, MSN, MPH, PNP-C
The co-contributor for Chapter 7, Domestic and Family Vio-
Ann Eckhardt, PhD, RN lence Assessments, is a Pediatric Nurse Practitioner on the
The co-contributor for Chapter 1, Evidence-Based Assess- surgical trauma team at the UCSF Benioff Children’s Hospital
ment; Chapter 3, The Interview; Chapter 9, General Survey, Oakland. She is on the hospital’s forensic center for child
Measurement, Vital Signs; the new adult case studies; and the protection team, serving children who have endured possible
electronic health recording content in Chapter 29 is an assis- abuse and neglect. She conducts domestic violence research
tant professor in the School of Nursing at Illinois Wesleyan to help keep women and college students safe in their
University. She received her PhD from the University of Illi- relationships.
nois at Chicago and has over a decade of clinical experience
in critical care and nursing leadership. Her research focus is Shawna S. Mudd, DNP, PNP-BC, CPNP-AC
symptomatology in heart disease. Dr. Mudd is a co-contributor for Chapter 7, Domestic and
Family Violence Assessments. She is an Assistant Professor at
Carla Graf, PhD, RN, CNS-BC The Johns Hopkins University School of Nursing and senior
The co-contributor for Chapter 31, Functional Assessment of pediatric nurse practitioner in the pediatric emergency
the Older Adult, is a board-certified Geriatric Clinical Nurse department at The Johns Hopkins Hospital.
Specialist and is an Assistant Clinical Professor at the Univer-
sity of California San Francisco School of Nursing. She is Daniel J. Sheridan, PhD, RN, FAAN
currently the Manager for Innovations in Transitions of Care The co-contributor for Chapter 7, Domestic and Family
at UCSF Medical Center. Violence Assessments, is a Professor at the Goldfarb School
of Nursing Graduate Studies Department at Barnes-Jewish
Amanda F. Hopkins, PhD, RN College. Dr. Sheridan is also an adjunct Associate Professor
Dr. Hopkins contributed the pediatric case studies within at the Flinders University School of Nursing and Midwifery
each of the body systems chapters. She is an Assistant Profes- in Adelaide, South Australia. Dr. Sheridan has 30 years of
sor in the School of Nursing at Illinois Wesleyan University. research and experience working with survivors of family
She specializes in pediatric health care and cross-cultural abuse and sexual assault.
awareness.
vi
Contributors vii
Jennifer Taylor Alderman, MSN, RNC-OB, CNL Gwen Sherwood, PhD, RN, FAAN
Clinical Assistant Professor/Academic Counselor Professor and Associate Dean for Academic Affairs
School of Nursing University of North Carolina at Chapel Hill
The University of North Carolina at Chapel Hill Chapel Hill, North Carolina
Chapel Hill, North Carolina
Constance Sinclair, CNM, MSN
Susan Caplan, PhD, MSN, FNP-BC Chief Nurse-Midwife
Assistant Professor Kaiser Santa Rosa Medical Center
Rutgers University Santa Rosa, California
Newark, New Jersey
Tammy Spencer, RN, MS, CNE, ACNS-BC, CCNS
Elizabeth Day, RN, MSN, CHPN Senior Instructor
Nursing Faculty University of Colorado
Fresno City College; College of Nursing
Academic Faculty Aurora, Colorado
University of Phoenix
Fresno, California Troy Spicer, MS, FNP-BC
Dean and Associate Professor
Debra B. Gordon, RN-BC, MS, DNP, ACNS-BC, FAAN School of Nursing and Health Sciences
Teaching Associate Abraham Baldwin Agricultural College
Department of Anesthesiology & Pain Medicine Tifton, Georgia
University of Washington
Seattle, Washington Mary Charles Sutphin, MSN, CNM
Certified Nurse Midwife
Christine Kessel, PhD, MSN, RN, CNE Clinical Instructor
Professor University of North Carolina School of Nursing
Trinity College of Nursing and Health Sciences Chapel Hill, North Carolina
Rock Island, Illinois
Christina Tomkins, RN, MSN, CEN, CCRN, CRNP, PHRN
Karen Klosinski, PhD(c), MSN/Ed, RN Assistant Professor
Assistant Professor of Nursing Misericordia University
Purdue University North Central Dallas, Pennsylvania
Westville, Indiana
Jo A. Voss, PhD, RN, CNS
Mary Lashley, PhD, RN, APHN, BC Associate Professor
Professor South Dakota State University
Community Health Nursing West River Department of Nursing
Towson University Rapid City, South Dakota
Towson, Maryland
viii
P R E FAC E
This book is for those who still carefully examine their examination techniques are explained and included depend-
patients and for those of you who wish to learn how to do so. ing on current clinical evidence.
You develop and practice, and then learn to trust, your health Pat Thomas has designed 32 new art pieces in beautiful
history and physical examination skills. In this book, I give detail. We have worked together to design new teaching tables
you the tools to do that. Learn to listen to the patient—most for students; note Table 13-4, Thyroid Hormone Disorders;
often he or she will tell you what is wrong (and right) and Fig. 19-12; Jugular venous pulsations; Table 21-2, Clinical
what you can do to meet his or her health care needs. Then Portrait of Intestinal Obstruction; Fig. 23-59 The Glascow
learn to inspect, examine, and listen to the person’s body. The Coma Scale; Table 23-6, Ischemic and Hemorrhagic Stroke;
data are all there and are accessible to you by using just a few and many others. Kevin Strandberg and I have had many new
extra tools. High-tech machinery is a smart and sophisticated photo shoots, replacing exam photos in Chapter 18, Thorax
adjunct, but it cannot replace your own bedside assessment and Lungs, and many others.
of your patient. Whether you are a beginning examiner or an All Promoting a Healthy Lifestyle boxes have been rewrit-
advanced-practice student, this book holds the content you ten to respond to current health-related concerns. These
need to develop and refine your clinical skills. boxes describe an important teaching topic related to the
body system discussed in each chapter—a teaching topic you
can use to enhance patient health. Also, new content on
obesity is added to numerous chapters to address the impor-
NEW TO THE SEVENTH EDITION tant role we health care providers have in assessing and
The 7th edition retains the strengths of the first six editions: addressing obesity in adults and children.
a clear, approachable writing style; an attractive and user- The Abnormal Findings tables located at the end of the
friendly format; integrated developmental variations across chapters are revised and updated with many new clinical
the life span with age-specific content on the infant, child, photos. These are still divided into two sections. The Abnor-
adolescent, pregnant woman, and older adult; cultural com- mal Findings tables present frequently encountered condi-
petencies in both a separate chapter and throughout the tions that every clinician should recognize, and the Abnormal
book; hundreds of meticulously prepared full-color illustra- Findings for Advanced Practice tables isolate the detailed
tions; sample documentation of normal and abnormal find- illustrated atlas of conditions encountered in advanced prac-
ings and 60 clinical case studies; integration of the complete tice roles.
health assessment in 2 photo essays at the end of the book All chapters are revised and updated, with accurate
where all key steps of a complete head-to-toe examination of coverage in anatomy and physiology, physical examination,
the adult, infant, and child are summarized; and a photo essay and assessment tools. Developmental Competence sections
highlighting a condensed head-to-toe assessment for each provide updated growth and development information, and
daily shift of nursing care. the Examination section of each body system chapter details
The 7th edition has a new chapter section and several exam techniques and clinical findings for infants, children,
new content features. A new Electronic Health Recording adolescents, and aging adults.
section in Chapter 29 discusses the documenting of assess- Culture and Genetics data have been revised and updated
ment findings with the new technology. Chapter 28 is a in each chapter. Together with a revised Chapter 2 on cultural
new photo essay on the complete physical assessment of the competence, these data highlight the importance of diversity
Infant, Child, and Adolescent. There are 45 new clinical case and cultural awareness.
studies and 15 revised studies of frequently encountered Chapter bibliographies are up-to-date and are meant to
situations that show the application of assessment techniques be used. They include the best of clinical practice readings as
to patients of varying ages and clinical situations. These case well as basic science research and nursing research, with an
histories, in SOAP format ending in diagnosis, use the actual emphasis on scholarship from the last 5 years.
language of recording. Diagnoses are derived from assess-
ment data and show the relationship between medical and
nursing diagnoses. I encourage professors and students to
use these as critical thinking exercises to discuss and develop
DUAL FOCUS AS TEXT AND REFERENCE
a Plan for each one. Physical Examination & Health Assessment is a text for begin-
My focus throughout is evidence-based practice. Chapter ning students of physical examination as well as a text and
1, Evidence-Based Assessment, is reoriented to conducting reference for advanced practitioners. The chapter progres-
the most effective, accurate exams based on data showing sion and format permit this scope without sacrificing one use
their usefulness in patient assessment. Throughout the text, for the other.
ix
x Preface
Chapters 1 through 7 focus on health assessment of the opmental content. Developmental anatomy, modifications
whole person, including health promotion for all age-groups, of examination technique, and expected findings are given
cultural environment and assessment, interviewing and com- for infants and children, adolescents, pregnant females,
plete health history gathering, the social environment of and aging adults.
mental status, and the changes to the whole person on the
occasions of substance use or domestic violence.
Chapters 8 through 11 begin the approach to the clinical
FEATURES FROM EARLIER EDITIONS
care setting, describing physical data-gathering techniques, Physical Examination & Health Assessment is built on the
how to set up the examination site, body measurement and strengths of the previous edition and is designed to engage
vital signs, pain assessment, and nutritional assessment. students and enhance learning:
Chapters 12 through 26 focus on the physical examina- 1. Method of examination (Objective Data section) is clear,
tion and related health history in a body systems approach. orderly, and easy to follow. Hundreds of original exami-
This is the most efficient method of performing the examina- nation illustrations are placed directly with the text to
tion and is the most logical method for student learning demonstrate the physical examination in a step-by-step
and retrieval of data. Both the novice and the advanced prac- format.
titioner can review anatomy and physiology; learn the skills, 2. Two-column format begins in the Subjective Data
expected findings, and common variations for generally section, where the running column highlights the ratio-
healthy people; and study a comprehensive atlas of abnormal nales for asking history questions. In the Objective Data
findings. section, the running column highlights selected abnor-
Chapters 27 through 31 integrate the complete health mal findings to show a clear relationship between normal
assessment. Chapters 27, 28, and 29 present the choreogra- and abnormal findings.
phy of the head-to-toe exam for a complete screening exami- 3. Abnormal Findings tables organize and expand on
nation in various age-groups and for the focused exam in this material in the examination section. The atlas format of
unique chapter on a hospitalized adult. Chapters 30 and 31 these extensive collections of pathology and original
present special populations—the health assessment of the illustrations helps students recognize, sort, and describe
pregnant woman and the functional assessment of the older abnormal findings. When applicable, the text under a
adult, including assessment tools and caregiver and environ- table entry is presented in a Subjective Data–Objective
mental assessment. Data format.
This text is valuable to both advanced practice students 4. Genetics and racial variations in disease incidence and
and experienced clinicians because of its comprehensive response to treatment are cited throughout using current
approach. Physical Examination & Health Assessment can help research. The Jarvis text has the richest amount of
clinicians learn the skills for advanced practice, refresh their cultural-racial-genetic content available in any assess-
memory, review a specific examination technique when con- ment text.
fronted with an unfamiliar clinical situation, compare and 5. Developmental approach in each chapter presents a
label a diagnostic finding, and study the Abnormal Findings prototype for the adult, then age-specific content for
for Advanced Practice. the infant, child, adolescent, pregnant female, and aging
adult so students can learn common variations for all
age-groups.
CONCEPTUAL APPROACH 6. Cultural competencies are extensive throughout and
Physical Examination & Health Assessment is committed to: present the expected variations for culturally diverse
• Holism, the individual as a whole, both in wellness needs people. Chapter 2 keynotes the cultural content, includ-
and illness needs. ing customs to consider when planning the interview,
• Health promotion in the health history questions that cultural variations to consider when reviewing examina-
elicit self-care behaviors, the Promoting a Healthy Lifestyle tion findings, and a Heritage Assessment Guide.
boxes, nutrition information, and the self-examination 7. Stunning full-color art shows detailed human anatomy,
teaching presented for skin, breast, and testicles. physiology, examination techniques, and abnormal
• Contracting with the person as an active participant in findings.
health care by discussing what the person currently is 8. Health history (Subjective Data) appears in two places:
doing to promote health and by engaging the person to (1) in Chapter 4, The Complete Health History, and (2)
participate in self-care. in pertinent history questions that are repeated and
• Cultural competencies that take into account this expanded in each regional examination chapter, includ-
global society in which culturally diverse people seek ing history questions that highlight health promotion
health care. and self-care. This presentation helps students under-
• Individuals across the life cycle, supporting the belief that stand the relationship between subjective and objective
a person’s state of health must be considered in light of data. Considering the history and examination data
developmental stage. All chapters integrate relevant devel- together, as you do in the clinical setting, means that each
Preface xi
chapter can stand on its own if a person has a specific including clips on the pregnant woman. Animations,
problem related to that body system. sounds, images, interactive activities, and video clips are
Chapter 3, The Interview, has the most complete dis- embedded in the learning modules and cases to provide a
cussion available on the process of communication, dynamic, multimodal learning environment for today’s
interviewing skills, techniques and traps, and cultural learners.
considerations (for example, how nonverbal behavior • Physical Examination & Health Assessment Video Series
varies cross-culturally and the use of an interpreter). is an 18-video package developed in conjunction with this
9. Summary checklists at the end of each chapter provide text. There are 12 body system videos and 6 head-to-toe
a quick review of examination steps to help develop a videos, with the latter containing complete examinations
mental checklist. of the neonate, child, adult, older adult, pregnant woman,
10. Sample recordings of normal and abnormal findings and the bedside examination of a hospitalized adult. This
show the written language you should use so that docu- series is available in DVD or streaming online formats.
mentation, whether written or electronic, is complete yet There are over 5 hours of video footage with highlighted
succinct. Cross-Cultural Care Considerations, Developmental Con-
11. Integration of the complete health assessment for the siderations, and Health Promotion Tips, as well as Instruc-
adult, infant, and child is presented as illustrated essays tor Booklets with video overviews, outlines, learning
in Chapters 27 and 28. This approach integrates all the objectives, discussion topics, and questions with answers.
steps into a choreographed whole. Included is a complete • The companion EVOLVE Website (http://evolve.elsevier
write-up of a health history and physical examination. .com/Jarvis/) contains learning objectives, more than 300
12. User-friendly design makes the book easy to use. Fre- multiple-choice and alternate-format review questions,
quent subheadings and instructional headings assist in system-by-system exam summaries, bedside exam sum-
easy retrieval of material. maries, printable key points from the chapter, and a com-
13. Spanish-language translations highlight important prehensive physical exam form for the adult. Case
phrases for communication during the physical examina- studies—including a variety of developmental and cul-
tion and appear on the inside back cover. tural variables—help students apply health assessment
skills and knowledge. These include 25 in-depth case
studies with critical thinking questions and answer guide-
SUPPLEMENTS lines, as well as printable health promotion handouts. Also
• The Pocket Companion for Physical Examination & included is a complete Head-to-Toe Video Examination of
Health Assessment continues to be a handy and current the Adult that can be viewed in its entirety or by systems,
clinical reference that provides pertinent material in full as well as a new printable section on Quick Assessments
color, with over 200 illustrations from the textbook. for Common Conditions.
• The Laboratory Manual with physical examination forms • Simulation Learning System. The new Simulation Learn-
is a workbook, now in full color, that includes for each ing System (SLS) is an online toolkit that incorporates
chapter a student study guide, glossary of key terms, clini- medium- to high-fidelity simulation with scenarios that
cal objectives, regional write-up forms, and review ques- enhance the clinical decision-making skills of students. The
tions. The pages are perforated so students can use the SLS offers a comprehensive package of resources, including
regional write-up forms in the skills laboratory or in the leveled patient scenarios, detailed instructions for prepara-
clinical setting and turn them in to the instructor. This tion and implementation of the simulation experience,
edition adds review questions to help students prepare for debriefing questions that encourage critical thinking, and
the NCLEX® examination. learning resources to reinforce student comprehension.
• The revised Health Assessment Online is an innovative • For instructors, the Evolve website presents TEACH for
and dynamic teaching and learning tool with more than Nursing, PowerPoint slides with Audience Response Ques-
8000 electronic assets, including video clips, anatomic tions for iClicker and Case Studies, a comprehensive Image
overlays, animations, audio clips, interactive exercises, Collection, and a Test Bank. TEACH for Nurses provides
laboratory/diagnostic tests, review questions, and elec- annotated learning objectives, key terms, teaching strate-
tronic charting activities. Comprehensive Self-Paced gies for the classroom in a revised section with strategies
Learning Modules offer increased flexibility to faculty for both clinical and simulation lab use and a focus on
who wish to provide students with tutorial learning QSEN competencies, critical thinking exercises, websites,
modules and in-depth capstone case studies for each and performance checklists. The PowerPoint slides include
body system chapter in the text. The Capstone Case 2000 slides with integrated images. Audience Response
Studies now include Quality and Safety Challenge activ- Questions provide 90 questions for in-class student par-
ities. Additional Advance Practice Case Studies put the ticipation. A separate 1200-illustration Image Collection
student in the exam room and test history taking and is featured and, finally, the ExamView Test Bank has over
documentation skills. The comprehensive video clip 1000 multiple-choice and alternate-format questions with
library shows exam procedures across the life span, coded answers and rationales.
xii Preface
IN CONCLUSION
Throughout all stages of manuscript preparation and pro- wherever possible. Your comments and suggestions continue
duction, we make every effort to develop a book that is read- to be welcome for this edition.
able, informative, instructive, and vital. Thank you for your Carolyn Jarvis
enthusiastic response to the earlier editions of Physical Exam- c/o Education
ination & Health Assessment. I am grateful for your encour- Elsevier
agement and for your suggestions, which are incorporated 3251 Riverport Lane
Maryland Heights, MO 63043
AC K N OW L E D G M E N T S
I am grateful for the many talented and dedicated colleagues added 45 new case studies and scores of new art and tables,
who helped make the revision of the 7th edition of this text- and we still came out with comparable page length for the
book possible. 7th edition.
Thank you to the bright, hardworking professional team I have gifted artistic colleagues, who made this book such
at Elsevier. I am fortunate to have the support of Laurie a vibrant teaching display. Pat Thomas, Medical Illustrator, is
Gower, Content Development Manager. Laurie is positive and so talented and contributes format ideas as well as brilliant
skilled in directing the big picture of the books, as well as the drawings. Kevin Strandberg patiently sets up equipment for
endless details. She has a calm and forthright manner that is all our photo shoots and then captures lovely exam photos of
so welcome. Also, I am grateful to work daily with Heather children and adults. Julia Jarvis also photographed our infant
Bays, Senior Content Development Specialist. Heather juggled photos with patience and clarity.
all the deadlines, readied all the manuscript for production, I am fortunate to have dedicated research assistants. Molly
searched out endless photos for abnormal examination find- Gray Guenette searched and retrieved countless articles and
ings, kept current with the permissions, and so many other sources. She was always prompt and accurate. Karolina Sier-
daily details. Her work is pivotal to our success. I feel lucky zputowska just joined as a research assistant and has helped
she joined our team. in many ways. I am most grateful to Paul Jarvis, who read and
I had a wonderful production team and I am most grateful reread endless copies of galley and page proof, finding any
to them. Debbie Vogel, Publishing Services Manager, super- errors and making helpful suggestions.
vised the schedule for book production. I am especially grate- Thank you to the faculty and students who took the time
ful to Jodi Willard, Senior Project Manager, who has been in to write letters of suggestions and encouragement—your
daily contact to keep the production organized and moving. comments are gratefully received and are very helpful. I am
She works in so many extra ways to keep production on fortunate to have the skilled reviewers who spend time
schedule. I am pleased with the striking colors of the interior reading the chapter manuscript and making valuable
design of the 7th edition and the beautiful cover; both are the suggestions.
work of Julia Dummitt, Book Designer. The individual page Most important are the members of my wonderful family,
layout is the wonderful work of Leslie Foster, Illustrator/ growing in number and in support. Their constant encour-
Designer. Leslie hand-crafted every page, always planning agement has kept me going throughout this process.
how the page can be made better. Because of her work, I Carolyn Jarvis
xiii
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CONTENTS
xv
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CHAPTER 1
Evidence-Based Assessment
http://evolve.elsevier.com/Jarvis/
1
2 UNIT 1 Assessment of the Whole Person
ASSESSMENT
• Collect data:
Review of the clinical record
Health history
Physical examination
Functional assessment
Risk assessment
Review of the literature
• Use evidence-based assessment
techniques
• Document relevant data
DIAGNOSIS
EVALUATION
• Compare clinical findings with
• Progress toward outcomes normal and abnormal variation
• Conduct systematic, ongoing, and developmental events
criterion-based evaluation • Interpret data
• Include patient and significant others Identify clusters of clues
Make hypotheses
• Use ongoing assessment to revise
Test hypotheses
diagnoses, outcomes, plan
Derive diagnoses
• Disseminate results to patient
• Validate diagnoses
and family
• Document diagnoses
OUTCOME IDENTIFICATION
• Identify expected outcomes
• Individualize to the person
IMPLEMENTATION • Culturally appropriate
• Implement in a safe and timely manner • Realistic and measurable
• Use evidence-based interventions • Include a timeline
1-2
4 UNIT 1 Assessment of the Whole Person
Functioning at the level of expert in clinical judgment overlook based on natural assumptions. Rates of incorrect
includes using intuition (i.e., knowledge received as a whole). diagnoses are estimated to be as high as 10% to 15%, and one
Intuition is characterized by immediate recognition of of the primary causes of misdiagnosis is the clinician’s bias.12
patterns; expert practitioners learn to attend to a pattern An overweight young adult comes to your clinic for a sched-
of assessment data and act without consciously labeling it. uled physical examination. Are you making assumptions
Whereas the beginner operates more from a set of defined, about her lifestyle and eating habits? Make sure that you
structured rules, the expert practitioner uses intuitive links, double-check the accuracy of your data (subjective and objec-
has the ability to see salient issues in a patient situation, and tive), identify normal and abnormal findings, and group like
knows instant therapeutic responses.5 The expert has a store- findings together. For example, a man who has heart failure
house of experience concerning which interventions have may exhibit shortness of breath, palpitations, ankle edema,
been successful in the past. and weight gain. Alone each of these may appear unrelated,
For example, compare the actions of the nonexpert and but together they are signs of an exacerbation of heart failure.
the expert nurse in the following situation of a young man Once you have clustered items that are related, you are
with Pneumocystis jiroveci pneumonia: ready to identify relevant information and anything that does
not fit. In the case of your heart failure patient, his complaints
He was banging the side rails, making sounds, and pointing
of a headache may be viewed as unrelated to the primary
to his endotracheal tube. He was diaphoretic, gasping, and
frantic. The nurse put her hand on his arm and tried to diagnosis, whereas abdominal pain and difficulty buttoning
ascertain whether he had a sore throat from the tube. While his pants are related (presence of ascites). As you gather clini-
she was away from the bedside retrieving an analgesic, the cal cues and complete an assessment, also think about prior-
expert nurse strolled by, hesitated, listened, went to the man’s ity setting (Table 1-1).
bedside, reinflated the endotracheal cuff, and accepted the • First-level priority problems are those that are emergent,
patient’s look of gratitude because he was able to breathe life threatening, and immediate, such as establishing an
again. The nonexpert nurse was distressed that she had airway or supporting breathing.
misread the situation. The expert reviewed the signs of a leaky • Second-level priority problems are those that are next in
cuff with the nonexpert and pointed out that banging the side urgency—those requiring your prompt intervention to
rails and panic help differentiate acute respiratory distress
forestall further deterioration (e.g., mental status change,
from pain.15
acute pain, acute urinary elimination problems, untreated
The method of moving from novice to becoming an expert medical problems, abnormal laboratory values, risks of
practitioner is through the use of critical thinking. We all start infection, or risk to safety or security).
as novices, when we need the familiarity of clear-cut rules to • Third-level priority problems are those that are impor-
guide actions. Critical thinking is the means by which we tant to the patient’s health but can be addressed after more
learn to assess and modify, if indicated, before acting. We may urgent health problems are addressed. Interventions to
even be beginners more than once during our careers. As we treat these problems are more long term, and the response
transition to different specialties, we must rebuild our data- to treatment is expected to take more time.
base of experiences to become experts in new areas of • Collaborative problems are those in which the approach
practice. to treatment involves multiple disciplines. Collaborative
Critical thinking is required for sound diagnostic reason- problems are certain physiologic conditions in which
ing and clinical judgment. During your career you will need nurses have the primary responsibility to diagnose the
to sort through vast amounts of data to make the sound judg- onset and monitor the changes in status.8 For example,
ments to manage patient care. These data will be dynamic, C.D.’s data regarding diabetes represent a collaborative
unpredictable, and ever changing. There will not be any problem. With this problem the sudden imbalance of
one protocol you can memorize that will apply to every insulin and blood sugar has profound implications on the
situation. central nervous and gastrointestinal (GI) systems. Her care
Critical thinking is recognized as an important compo- will be monitored by nurses, doctors, dietitians, and case
nent of nursing education at all levels.2,20 Case studies and managers. Or another patient with an alcohol-use disorder
simulations frequently are used to encourage critical thinking presents to the hospital for unrelated surgery and experi-
with students. As a student, be prepared to think outside the ences sudden alcohol withdrawal symptoms. This causes
box and think critically through patient-care situations. Criti- rebound effects on the central nervous and cardiovascular
cal thinking goes beyond knowing the pathophysiology of a systems that must be managed by a team of clinicians.
disease process and requires you to put important assessment Once you have determined problems, you must identify
cues together to determine the most likely cause of a clinical expected outcomes and work with the patient to facilitate
problem and develop a solution. Critical thinking is a multi- outcome achievement. Remember, your outcomes need to be
dimensional thinking process, not a linear approach to measurable. Set small goals that can be accomplished in a
problem solving. given time frame. For your heart failure patient your goal may
Remember to approach problems in a nonjudgmental way be to eliminate supplemental oxygen needs before discharge.
and to avoid making assumptions. Identify which informa- Include your patient in your outcome identification and his
tion you are taking for granted or information you may or her input as appropriate.
CHAPTER 1 Evidence-Based Assessment 5
In acute hospital care the complete database also is gath- both within the person and from the external environment.
ered on admission to the hospital. In the hospital, data related Thus the treatment of disease requires the services of numer-
specifically to pathology may be collected by the admitting ous providers. Nursing includes many aspects of the holistic
physician. You collect additional information on the patient’s model (i.e., the interaction of the mind and body, the oneness
perception of illness, functional ability or patterns of living, and unity of the individual). Both the individual human and
activities of daily living, health maintenance behaviors, the external environment are open systems, dynamic and
response to health problems, coping patterns, interaction pat- continually changing and adapting to one another. Each
terns, and health goals. person is responsible for his or her own personal health state
and is an active participant in health care. Health promotion
Focused or Problem-Centered Database and disease prevention form the core of nursing practice.
This is for a limited or short-term problem. Here you collect In a holistic model assessment factors are expanded to
a “mini” database, smaller in scope and more targeted than include such things as lifestyle behaviors, culture and values,
the complete database. It concerns mainly one problem, one family and social roles, self-care behaviors, job-related stress,
cue complex, or one body system. It is used in all settings— developmental tasks, and failures and frustrations of life. All
hospital, primary care, or long-term care. For example, 2 days are significant to health.
after surgery a hospitalized person suddenly has a congested Health promotion and disease prevention now round
cough, shortness of breath, and fatigue. The history and out our concept of health. Guidelines to prevention empha-
examination focus primarily on the respiratory and cardio- size the link between health and personal behavior. The
vascular systems. Or in an outpatient clinic a person presents report of the U.S. Preventive Services Task Force26 asserts that
with a rash. The history follows the direction of this present- the great majority of deaths among Americans younger than
ing concern such as whether the rash had an acute or chronic 65 years are preventable. Prevention can be achieved through
onset; was associated with a fever, new food, pet, or medicine; counseling from primary care providers designed to change
and was localized or generalized. Physical examination must people’s unhealthy behaviors related to smoking, alcohol and
include a clear description of the rash. other drug use, lack of exercise, poor nutrition, injuries, and
sexually transmitted infections.14 Health promotion is a set
Follow-Up Database of positive acts that we can take. In this model the focus of
The status of any identified problems should be evaluated at the health professional is on teaching and helping the con-
regular and appropriate intervals. What change has occurred? sumer choose a healthier lifestyle.
Is the problem getting better or worse? Which coping strate- The frequency interval of assessment varies with the per-
gies are used? This type of database is used in all settings to son’s illness and wellness needs. Most ill people seek care
follow up both short-term and chronic health problems. because of pain or some abnormal signs and symptoms they
have noticed, which prompts an assessment (i.e., gathering a
Emergency Database complete, a focused, or an emergency database). In addition,
This is an urgent, rapid collection of crucial information and risk assessment and preventive services can be delivered once
often is compiled concurrently with lifesaving measures. the presenting concerns are addressed (Fig. 1-4).
Diagnosis must be swift and sure. For example, a person is But for the well person opinions are inconsistent about
brought into a hospital ED with suspected substance over- assessment intervals. The term annual checkup is vague. What
dose. The first history questions are, “What did you take?” does it constitute? Is it necessary or cost-effective? How can
“How much did you take?” and “When?” The person is ques- primary-care clinicians deliver preventive services to people
tioned simultaneously while his or her airway, breathing, cir- with no signs and symptoms of illness? Periodic health check-
culation, level of consciousness, and disability are being ups are an excellent opportunity to deliver preventive services
assessed. Clearly the emergency database requires more rapid and update the complete database. Although periodic health
collection of data than the episodic database. Once the person
has been stabilized, a complete database can be compiled.
checkups could induce unnecessary costs and promote non- In 2043 the United States is expected to become a majority-
recommended services, advocates justify well-person visits minority nation. Although non-Hispanic Whites will remain
because of delivery of some recommended preventive ser- the largest single group, they will no longer constitute a
vices and reduction of patient worry.7 numeric majority. By 2060 the U.S. Census Bureau projects
The Guide to Clinical Preventive Services is a positive that minorities will comprise 57% of the population. The
approach to health assessment and risk reduction.26 The Hispanic and Asian populations are projected to more than
Guide is updated annually and is accessible online or in print. double by 2060, and all other racial groups are expected to
It presents evidence-based, gold standard recommendations increase as well. By 2060 nearly 33% of the population will be
on screening, counseling, and preventive topics and includes Hispanic, 15% Blacks, 8.2% Asian, and 1.5% American Indians
clinical considerations for each topic. These services include or Alaska Natives. In 2050 the U.S. Census Bureau anticipates
screening factors to gather during the history, age-specific that there will be more people over the age of 65 years than
items for physical examination and laboratory procedures, under the age of 18 years for the first time in history.25
counseling topics, and immunizations. This approach moves As the United States population is becoming more diverse,
away from an annual physical ritual and toward a rational the U.S. health care providers go abroad to work in a variety
and varying periodicity based on factors specific to the patient. of health care settings in the international community.
Health education and counseling are highlighted as the means Medical and nursing teams volunteer to provide free medical
to deliver health promotion and disease prevention. and surgical care in developing countries (Fig. 1-5). Interna-
For example, the guide to examination for C.D. (23-year- tional interchanges are increasing among health care provid-
old female, nonpregnant, not sexually active) would recom- ers, making attention to the cultural aspects of health and
mend the following services for preventive health care: illness an even greater priority.
1. Screening history for dietary intake, physical activity, During your professional career you may be expected to
tobacco/alcohol/drug use, and sexual practices assess short-term foreign visitors who travel for treatments,
2. Physical examination for height and weight, BP, and international university faculty, students from abroad study-
screening for cervical cancer and HIV ing in U.S. high schools and universities, family members of
3. Counseling for physical activity and risk prevention foreign diplomats, immigrants, refugees, members of more
(e.g., secondhand smoke, seatbelt use) than 106 different ethnic groups, and American Indians from
4. Depression screening 510 federally recognized tribes. A serious conceptual problem
5. Healthy diet counseling, including lipid disorder exists in that nurses and physicians are expected to know,
screening and obesity screening understand, and meet the health needs of people from cultur-
6. Chemoprophylaxis to include multivitamin with folic ally diverse backgrounds with minimal preparation in cul-
acid (females capable of or planning pregnancy) tural competence.
C.D. is living successfully with a serious chronic condition. Culture has been included in each chapter of this book.
Because she has diabetes, including periodic checks of hemo- Understanding the basics of a variety of cultures is important
globin A1c and a fasting glucose level is important. In addi- in health assessment. People from different cultures may inter-
tion, you should ask how her pump is functioning and pret symptoms differently; therefore asking the right ques-
whether she is having any difficulties with blood sugar control. tions is imperative for you to gather data that are accurate and
meaningful. Members of some cultural groups are demanding
culturally relevant health care that incorporates their specific
CULTURE AND GENETICS beliefs and practices. An increasing expectation exists among
In a holistic model of health care, assessment factors must
include culture. An introduction to cross-cultural concepts
follows in Chapter 2. These concepts are developed through-
out the text as they relate to specific chapters.
Metaphors such as melting pot, mosaic, and salad bowl have
been used to describe the cultural diversity that characterizes
the United States. According to the U.S. Census Bureau, close
to 50% of the population of the United States will consist
of people from diverse racial, ethnic, and cultural groups by
the year 2050. Emerging minority is a term that has been used
to classify the populations, including Blacks, Hispanics, and
Asian Americans, that are rapidly becoming a combined
numeric majority.22
The population of the United States surpassed 311 million
people in the autumn of 2011; approximately 1 in 3 U.S. resi-
dents was part of a group other than single-race non-Hispanic
Whites according to national estimates by race, Hispanic
origin, and age released by the Census Bureau. 1-5
CHAPTER 1 Evidence-Based Assessment 9
members of certain cultural groups that health care providers Given the multicultural composition of the United States
will respect their “cultural health rights,” an expectation that and the projected increase in the number of individuals from
may conflict with the unicultural Western biomedical world- diverse cultural backgrounds anticipated in the future, a
view taught in U.S. educational programs that prepare nurses, concern for the cultural beliefs and practices of people is
doctors, and other health care providers. increasingly important.
BIBLIOGRAPHY
1. Alfaro-LeFevre, R. (2013). Critical thinking, clinical reasoning 15. Hanneman, S. K. (1996). Advancing nursing practice with a
and clinical judgment. (5th ed.). St. Louis: Saunders. unit-based clinical expert. Image, 28(4), 331-337.
2. American Association of Colleges of Nursing. (2008). 16. Leufer, T. C. (2009). Evidence-based practice: improving
Essentials of baccalaureate education for professional nursing patient outcomes. Nurs Stand, 23(32), 35-39.
practice. Available at https://www.aacn.nche.edu/education- 17. Madsen, D., Sebolt, T., Cullen, L., et al. (2005). Listening to
resources/baccessentials08.pdf. bowel sounds: an evidence-based practice project. Am J Nurs,
3. American Nurses Association. (2010). Nursing scope and 105(12), 40-50.
standards of performance and standards of clinical practice. 18. Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based
Washington, DC: American Nurses Publishing. practice in nursing & healthcare. (2nd ed.). Philadelphia:
4. Balas, E. A., & Boren, S. A. (2000). Managing clinical Lippincott Williams & Wilkins.
knowledge for health care improvements. In Bemmel, J., & 19. Melnyk, B. M., Fineout-Overhold, E., Stillwell, B., et al. (2009).
A. T. McCray (Eds.). Yearbook of medical informatics 2000. Evidence-based practice step by step: igniting the spirit of
Stuttgart, Germany: Schattauer. inquiry. Am J Nurs, 109(11), 49-52. First in a 12-part series.
5. Benner, P., Tanner, C. A., & Chesla, C. A. (1996). Expertise in 20. National League for Nursing Accrediting Commission. (2006).
nursing practice. New York: Springer. Accreditation manual and interpretive guidelines by program
6. Benner, P., Tanner, C. A., & Chesla, C. A. (1997). Becoming an type for postsecondary and higher degree programs in nursing.
expert nurse. Am J Nurs, 97(6), 16BBB-16DDD. New York: Author.
7. Boulware, L. E., Marinopoulos, S., & Phillips, K. A. (2007). 21. Robert, R. R., & Petersen, S. (2013). Critical thinking at the
Systematic review: the value of the periodic health evaluation. bedside: providing safe passage to patients. Medsurg Nurs,
Ann Intern Med, 146(4), 289-300. 22(2):85-93.
8. Carpenito-Moyet, L. J. (2012). Nursing diagnosis: application 22. Spector, R. E. (2013). Cultural diversity in health and illness.
to clinical practice. (14th ed.). Philadelphia: Lippincott (8th ed.). Indianapolis, IN: Pearson.
Williams & Wilkins. 23. Throckmorton, T., & Windle, P. E. (2009). Evidence-based
9. Cochrane Collaboration. (2013). Available at case management practice. Part 1: the systemic review. Prof
www.cochrane.org. Case Manage, 14(2), 76-81.
10. Coderre, S., Mandin, H., Harasym, P. H., et al. (2003). 24. U.S. Bureau of the Census. (2014). Quickfacts. Washington,
Diagnostic reasoning strategies and diagnostic success. DC: U.S. Government Printing Office. www.census.gov.
Med Educ, 37(8), 695-703. 25. U.S. Census Bureau. (2012). U.S. Census Bureau projections
11. Crisp, N., & Chen, L. (2014). Global supply of health show a slower growing, older, more diverse nation a half century
professionals. N Engl J Med, 370(10), 950-957. from now. Available at https://www.census.gov/newsroom/
12. Croskerry, P. (2013). From mindless to mindful practice— releases/archives/population/cb12-243.html.
cognitive bias and clinical decision making. N Engl J Med, 26. U.S. Preventive Services Task Force (USPSTF). (2012).
368, 2445-2450. Guide to clinical preventive services. (2012). Available at
13. DiCenso, A., Guyatt, G., & Ciliska, D. (2005). Evidence-based http://www.ahrq.gov/professionals/clinicians-providers/
nursing: a guide to clinical practice. St. Louis: Mosby. guidelines-recommendations/guide/guide-clinical-preventive
14. Ezzati, M., & Riboli, E. (2013). Behavioral and dietary risk -services.pdf.
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369(10):954-964.
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CHAPTER 2
Cultural Competence
http://evolve.elsevier.com/Jarvis/
DEMOGRAPHIC PROFILE
OF THE UNITED STATES
The estimates of the U.S. population illustrate the increasing
diversity in the population and explain the rationale for
2-1 learning about the cultural aspects of health* and illness†
from the point of view of the person seeking health care.46
The population of the United States exceeded 311 million
A health profession role encompasses your relationships with people in 2011.44 Approximately 1 in every 6 to 7 people was
people—your ability to listen to, empathize with, and under- an immigrant, and greater than one third of U.S. residents
stand people. How can you fulfill this role to the best of your were part of a group other than single-race non-Hispanic
ability? First be open to people who are different from you, White.27,44 The national minority, actually emerging majority,
have a curiosity about people, and begin the lifelong journey population totaled 37% of the total population.27 Among this
of becoming culturally competent (Fig. 2-1). The United emerging majority, the largest ethnic group is Hispanic, who
States is becoming more diverse, not only through globaliza- make up 16.7% of the population and are the fastest-growing
tion and immigration, but also because of a wide range of minority group. The largest racial minority group is African
subcultures and an increasing acceptance of lifestyle choices American or Black (12.2%), followed by Asians (4.8%), other
that may differ from the mainstream. For example, in 2011 races (4.7%), two or more races (2.8%), American Indians
approximately 4% of the U.S. adult population (or 9 million and Alaska natives (0.8%), and Native Hawaiians and other
people) identified themselves as lesbian, gay, bisexual, or Pacific Islanders (0.2%).44
transgender (LGBT), and even larger numbers stated that There are differences among the emerging majority groups
they had same-sex experiences or were attracted to the same when compared to non-Hispanic Whites. These demo-
sex without necessarily identifying themselves as LGB.16 graphic differences are age, poverty level, and household
A key to understanding cultural diversity is self-awareness
and knowledge of one’s own culture, which may be African
*Health: “The balance of the person, both within one’s being (i.e.,
American, Euro American, Chinese American, Dominican physical, mental, and/or spiritual) and in the outside world (i.e.,
American, Mexican American, Southeast Asian–American, or natural, communal, and/or metaphysical), is a complex, interrelated
any combination of self-identified ethnicities and races. Your phenomenon.”41
cultural identification might include the subculture of †Illness: “The loss of the person’s balance, both within one’s being
nursing or health care professionals. You might identify your- (i.e., physical, mental, and/or spiritual) and in the outside world (i.e.,
self as a Midwesterner, a college student, an athlete, a member natural, communal, and/or metaphysical).”41
11
12 UNIT 1 Assessment of the Whole Person
composition. The median age of the non-Hispanic White understanding of health care resources and how to navigate
population in 2012 was 40.2 years, and one fourth was the health care system. They may not speak or understand
younger than 18 years. The median age of some racial and English, and they may not be literate in the language of their
ethnic groups was younger than the total population as a country of origin. Therefore it is imperative that health care
whole. Hispanics had the youngest median age (27.7 years), address the needs of this growing population.
followed by Native Hawaiian/Pacific Islanders (30.4 years), In 2011 the population in the United States included over
American Indians and Alaska Natives (31.9 years), African 40 million foreign-born people, including legal and undocu-
Americans, (32.9 years), and Asians (36 years).44 The family mented immigrants, representing 13% of the U.S. population
size of some racial and ethnic groups is larger than that of and an increase of 9 million people since 2000.27,44 Although
non-Hispanic Whites (3.14 people). Native Hawaiian/Pacific the number of foreign born is the greatest in U.S. history, the
Islanders have the largest average family size (4.16 people), foreign born as a percent of the entire population does not
followed by Hispanics, (3.95 people), American Indians and reach the high point in American history (i.e., from 1890
Alaska Natives (3.68 people), Asians (3.61 people), and to1920) when immigrants from Southern and Eastern Europe
African Americans (3.47 people).44 The number of relatives made up 15% of the population.36 The current wave of immi-
living in the household is higher for all racial and ethnic grants is predominantly from Latin America (50%) and Asia
minorities compared to non-Hispanic Whites, as is the (27%). Mexico has by far the largest number of immigrants
number of multigenerational families. African Americans, to the U.S. at 29% of the foreign-born population, followed
American Indians, and Alaska Natives are more likely to have by India at 4.6%, the Philippines at 4.5%, China at 4.1%, and
grandparents who are responsible for the care of grandchil- Vietnam at 3.1%.36
dren compared with other groups.44 The Immigration and Nationality Act of 1965 abolished
All ethnic and racial minority groups have poverty rates quota systems that denied entrance into the United States to
exceeding the national average for non-Hispanic Whites of Latin Americans, Asians, and Africans, thus opening the way
13%.44 American Indians and Alaska Natives (29.1%), African for the current wave of immigration. In 2011 there were
Americans, (28.1%), and Hispanics (25.4%) have about twice also 11.1 million people who were foreign born and living
as many people living in poverty as non-Hispanic Whites.44 in the United States without legal documents (unauthorized
Contributing to the high rates of poverty is low educational or undocumented immigrants), which decreased from 12
attainment. Thirty six percent of Hispanics, 21% of American million in 2007. This is the result of a decrease or reversal of
Indians and Alaska Natives, and 17% of Blacks have less than net immigration from Mexico, the origin of the largest
a high school education compared to 12% of non-Hispanic number of unauthorized immigrants.34 The new wave of
Whites.44 Female-headed households with children under 18 immigration and the numbers of unauthorized immigrants
years are most likely to be living in poverty. Dominicans, have engendered a great deal of controversy in the United
Puerto Ricans, Somalians, and African Americans are 3 times States and have prompted new policy changes. The proposed
more likely to be in female-headed households with children Immigration Reform Bill would create a mechanism for the
under 18 compared to non-Hispanic Whites.46 Ten percent of 11 million undocumented immigrants to achieve legal citi-
the population is living with a disability; this rate is higher zenship after proving that they can speak English, pass back-
among African Americans (13.6%) and American Indians ground checks, and pay taxes and a penalty.7
and Alaska Natives (16.7%).44
Within these groups are subgroup variations (e.g., Cubans DETERMINANTS OF HEALTH
in the U.S. have a median age of 39.8 years, whereas Guate-
malans have a median age of 27.8 years). In terms of educa-
AND HEALTH DISPARITIES
tional attainment: more than half of Guatemalans, Mexicans, An individual’s health status is influenced by a constellation
and Salvadorans have less than a high school education com- of personal, social, economic, and environmental factors, col-
pared to 9% of Chileans; 36% of Somalis have less than a high lectively known as the Determinants of Health.45 The determi-
school education compared to 4% of Nigerians; 19% of nants of health comprise political action and legislation;
Koreans have a graduate or professional degree compared to health care services; social factors such as poverty, occupa-
4% of Cambodians.44 Among Asian ethnic groups, poverty tional status, the quality of the neighborhood, and environ-
rates are highest for Hmong (27%) and Cambodians (21%) ment; lifestyle factors and individual behaviors; and biology
compared to Japanese (8.5%). Among Hispanics, poverty and genetics. However, evidenced-based research has consis-
rates are highest for Dominicans and Hondurans (29%), fol- tently shown that poverty has the greatest influence on health
lowed by Guatemalans and Mexicans (28%) and Puerto status.
Ricans (27%), compared to Bolivians at 9%.44 The purposes of Healthy People 2020 are to address the
multiple determinants of health and evaluate interventions
that go beyond the traditional health care provider–patient
IMMIGRATION model. For the past two decades the goals of Healthy People
Immigrants are people who are not U.S. citizens at birth. have been to eliminate health disparities. Healthy People
The United States accepts more immigrants than any other 2020 defines a health disparity as “a particular type of health
county in the world.36 Some new immigrants have minimal difference that is closely linked with social, economic,
CHAPTER 2 Cultural Competence 13
and/or environmental disadvantage. Health disparities Non-Hispanic Whites had the highest rates of all racial
adversely affect groups of people who have systematically and ethnic groups in drug-induced deaths and death from
experienced greater obstacles to health based on their racial cirrhosis, death by poisoning, smoking in pregnant women,
or ethnic group; religion; socioeconomic status; gender; age; physical assault, chronic obstructive pulmonary disease,
mental health; cognitive, sensory, or physical disability; binge drinking among high school seniors, firearm-related
sexual orientation or gender identity; geographic location; or deaths, steroid use among 10th graders, and prostate cancer
other characteristics historically linked to discrimination or deaths.
exclusion.”45 Few of the differences in health between ethnic and racial
The new framework for health care delivery strives for groups have a biologic basis but rather pertain to the social
social and physical environments that promote quality of life determinants of health. Moreover, some differences suggest
free from preventable illness, disability, and premature death. the benefits of targeted educational strategies such as toward
This new framework encourages public health sectors to Asians’ lack of Pap testing, lower rates of self-monitoring for
address the needs for safe and affordable housing; reliable diabetes or fetal alcohol syndrome, and smoking by pregnant
transportation; nutritious food that is accessible to everyone; women among Alaska Natives and Pacific Islanders. However,
safe, well-integrated neighborhoods and schools; health care disparities in exposure to environmental contaminants, vio-
providers that are culturally and linguistically competent; and lence, and substance abuse among some racial and ethnic
clean water and air. minorities suggest the need for a major transformation of the
neighborhoods and social contexts of people’s lives.
Health Care Disparities Among Note that information regarding specific health disparities
Vulnerable Populations is included in the Culture and Genetics section of chap-
Health disparities or unfair and avoidable health differences ters in this text.
affect people who experience social, economic, and/or envi-
ronmental disadvantage. These people are “vulnerable popu- National Cultural and Linguistic Standards
lations” and include ethnic and racial minorities, people with The determinants of health most relevant to health care dis-
disabilities, and the LGBT community. Health care disparities parities fall under the areas of policy and legislation; health
can be measured by comparing the percent of difference from care services; social factors such as poverty, occupational
one group to the best group rate for a disease. Among African status, and the quality of the neighborhood and environment;
Americans the 7 largest health care disparities include gonor- lifestyle factors and individual behaviors; and biology and
rhea, congenital syphilis, new cases of acquired immunode- genetics. Many forms of discrimination based on race or
ficiency syndrome (AIDS), and deaths from AIDS—these national origin frequently limit the opportunities of people
reflect over 1000% difference from the group with the lowest to gain equal access to health care services. Many health and
indicators (Asians and/or Non-Hispanic Whites).19 These are social service programs provide information about their ser-
followed by nonfatal firearm-related injuries, new cases of vices in English only. It is said that “language barriers have a
tuberculosis, homicides, and drug-induced deaths. For His- deleterious effect on health care; patients are less likely to have
panics the five largest indicators of health disparities were a usual source of health care and have an increased risk of
congenital syphilis, new cases of tuberculosis, new cases of non-adherence to medication regimens.”15
AIDS, exposure to environmental contaminants, and cirrho- Because immigration occurs at high levels and immigrants
sis deaths. Following these are no source of ongoing care, with limited English proficiency (LEP) have particular needs,
drug-induced deaths, carbon monoxide poisoning, no com- the Office of Minority Health published the National Stan-
pletion of high school, and death from poisoning. The Ameri- dards for Culturally and Linguistically Appropriate Services in
can Indian or Alaska Native population also had the same Health Care. The first and landmark standard states: “Health
largest disparities as the Black non-Hispanic population, care organizations should ensure that patients receive from
including high rates of gonorrhea, new tuberculosis cases, and all staff members effective, understandable, and respectful
drug-induced deaths. Some of its largest disparities were care that is provided in a manner compatible with their cul-
similar to those of the Hispanic population: new cases of tural health beliefs and practices and preferred language.”29
tuberculosis, cirrhosis deaths, and deaths from poisoning. The • EFFECTIVE CARE results in positive outcomes and
American Indian or Alaska Native population had the highest satisfaction for the patient.
rates of fetal alcohol syndrome, smoking by pregnant women, • RESPECTFUL CARE takes into consideration the
alcohol-related motor vehicle deaths, and physical assault. values, preferences, and expressed needs of the patient.
The Asian population had the largest disparities in con- • CULTURAL AND LINGUISTIC COMPETENCE is a
genital syphilis and new tuberculosis cases and also had high set of congruent behaviors, attitudes, and policies that
rates of exposure to particulate matter, carbon monoxide, and come together in a system among professionals that
no source of ongoing care. In addition, the Asian population enables work in cross-cultural situations (Fig. 2-2).
had low rates of Pap testing, greater exposure to ozone,
greater lack of knowledge of stroke symptoms, and lower Linguistic Competence
rates of self-monitoring of blood glucose levels among people Under the provisions of Title VI of the Civil Rights Act of
with diabetes. 1964, when people with LEP seek health care in settings such
14 UNIT 1 Assessment of the Whole Person
Modified from Caplan, S. (2007). Latinos, acculturation, and acculturative stress: a dimensional concept analysis. Policy Politics Nurs Pract,
8(2), 93-106.
16 UNIT 1 Assessment of the Whole Person
2. Religious affiliation and membership benefit health by There are many examples of how spirituality and religion
promoting healthy behavior and lifestyles.29 are apparent in daily life and frequently play a role in one’s
3. Regular religious fellowship benefits health by offer- health. People may take religious pilgrimages to shrines.
ing social support. Faith benefits health by leading There are countless shrines, both secular and from a religious
to thoughts of hope, optimism, and positive tradition, which people visit to remember and/or pray for
expectation.8,31 favors or healing. Fig. 2-4, A, is an image of the Vietnam
In times of crisis such as serious illness and impending death, Veterans Memorial in Washington, DC, an example of a
religion may be a source of consolation for the person and secular/spiritual shrine where people go to remember loved
his or her family.32 Religious dogma and spiritual leaders may ones who died in the Vietnam War. Fig. 2-4, B, is a statue of
exert considerable influence on the person’s decision making Saint Peregrine, the patron saint of people with cancer, in the
concerning acceptable medical and surgical treatment such Mission San Juan Capistrano in California. Fig. 2-4, C, is the
as vaccinations, choice of healer(s), and other aspects of the Thai Spirit House in Los Angeles, California. The shrine is on
illness. a public street and is visited by believers; offerings such as
CHAPTER 2 Cultural Competence 17
flowers and food are frequently left at the base. Fig. 2-4, D, is TABLE 2-2 Spirituality Assessment: the
an example of a sacred Buddhist shrine that can be found in Brief R-COPE*
a store or in a home.
The following items deal with how you coped with a
In health care settings you frequently encounter people
significant trauma or negative event in your life. There are
who are searching for a spiritual meaning to help explain their
many ways to try to deal with problems. These items ask
illnesses or disabilities. Some health care providers find spiri- which part religion played in what you did to cope with
tual assessment difficult because of the abstract and personal this negative event. Obviously different people deal with
nature of the topic. This aspect of the person may be ignored, things in different ways, but we are interested in how
and the question “What is your religious preference?” is not you tried to deal with it. Each item says something about
asked. This may be to protect against discrimination based a particular way of coping. We want to know to what
on religion. Yet the omission of questions about spiritual and extent you did what the item says: how much or how
religious practices can raise barriers to holistic care. frequently. Don’t answer on the basis of what worked or
Several well-validated questionnaires assess how a person not—just whether or not you did it. Use these response
is coping with loss such as a serious illness. Perhaps the most choices.
Try to rate each item separately in your mind. Make your
well-known and widely used is the Brief R-COPE, a short
answers as true for you as you can.
14-item assessment for use in clinical practice (Table 2-2).33
1 = Not at all
The Brief R-COPE helps practitioners understand the 2 = Somewhat
patient’s religious coping to enable them to integrate spiritu- 3 = Quite a bit
ality in treatment.33It examines whether a patient is using 4 = A great deal
positive or negative religious coping. Positive religious coping 1. Looked for a stronger connection with God. _____
mechanisms indicate that the person is strongly connected to 2. Sought God’s love and care. _____
a divine presence, is spiritually connected with others, and 3. Sought help from God in letting go of my anger. _____
has a benevolent outlook on life, whereas negative religious 4. Tried to put my plans into action together with God.
coping methods reflect a spiritual struggle with one’s self or _____
with God. Illness may be attributed to God’s punishment, to 5. Tried to see how God might be trying to strengthen me
in this situation. _____
an act of the Devil, or totally within the hands of God. Just
6. Asked forgiveness for my sins. _____
as positive religious coping has been linked to positive health
7. Focused on religion to stop worrying about my
(described previously), negative religious coping is associated problems. _____
with poor health outcomes33 and provides an opportunity for 8. Wondered whether God had abandoned me. _____
the nurse to intervene. 9. Felt punished by God for my lack of devotion. _____
In summation we need to understand a patient’s cultural 10. Wondered what I did for God to punish me. _____
and religious beliefs because countless health-related behav- 11. Questioned God’s love for me. _____
iors are promoted by nearly all cultures and religions. Medi- 12. Wondered whether my church had abandoned me.
tating, exercising and maintaining physical fitness, getting _____
enough sleep, being willing to have the body examined, telling 13. Decided the devil made this happen. _____
the truth about how you feel, maintaining family viability, 14. Questioned the power of God. _____
hoping for recovery, coping with stress, being able to live with From Pargament, K., Feuille, M., & Burdzy, D. (2011). The Brief
a disability, and caring for children are all intricately related RCOPE: current psychometric status of a short measure of
to one’s core values and beliefs. religious coping. Religions 2, 51-76.
*The reproduction of any copyrighted material is prohibited without
the express permission of the copyright holder.
HEALTH-RELATED BELIEFS AND PRACTICES
Healing and Culture same disease that is considered grounds for social ostracism
Health is defined as the balance of the person, both within in one culture may be reason for increased status in another.
one’s being (physical, mental, or spiritual) and in the outside For example, epilepsy is seen as contagious and untreatable
world (natural, communal, or metaphysical). It is a complex, among Ugandans, as a cause for family shame among Greeks,
interrelated phenomenon. Before determining whether cul- as a reflection of a physical imbalance among Mexican Amer-
tural practices are helpful, harmful, or neutral, you must first icans, as the entry of a “spirit” into the person’s body by the
understand the logic of the traditional belief systems coming Hmong,14 and as a sign of having gained favor by enduring a
from a person’s culture and then grasp the nature and meaning trial by God among the Hutterites.
of the health practice from the person’s cultural perspective. Bodily symptoms are also perceived and reported in a
Wide cultural variation exists in the manner in which variety of ways. For example, people of Mediterranean descent
certain symptoms and disease conditions are perceived, diag- tend to report common physical symptoms more often than
nosed, labeled, and treated. You should not assume that the people of Northern European or Asian heritage. Among
perceived symptoms or complaints of patients are equivalent Chinese, no translation exists for the English word “sadness,”
to the names of recognized diseases or syndromes familiar to yet all people experience the feeling of sadness at some time
nurses, physicians, and other health care professionals.11 The in life. To express emotion, Chinese patients somaticize their
18 UNIT 1 Assessment of the Whole Person
symptoms or convert mental experiences or states into bodily balance.26 Rooted in the ancient Chinese philosophy of Tao,
symptoms (e.g., complain of cardiac symptoms because the the yin/yang theory states that all organisms and objects in
center of emotion in the Chinese culture is the heart). For the universe consist of yin and yang energy forces. The seat
example, you may collect in-depth data about the cardiovas- of the energy forces is within the autonomic nervous system,
cular system only to learn later that all diagnostic tests are where balance between the opposing forces is maintained
negative. On further assessment you find that the person has during health. Yin energy represents the female and negative
experienced a loss and is grieving (e.g., has experienced the forces such as emptiness, darkness, and cold, whereas yang
death of a close relative or friend or has been divorced or forces are male and positive, emitting warmth and fullness.
separated). This is a culturally acceptable somatic expression Foods are classified as hot and cold in this theory and are
of emotional disharmony. transformed into yin and yang energy when metabolized by
For patients, symptom labeling and diagnosis depend on the body. Yin foods are cold, and yang foods are hot. Cold
the degree of difference between the person’s behaviors and foods are eaten with a hot illness, and hot foods are eaten with
those that the group has defined as normal (e.g., beliefs about a cold illness. The yin/yang theory is the basis for Eastern or
the causation of illness, level of stigma attached to a particular Chinese medicine and is commonly embraced by many Asian
set of symptoms, prevalence of the pathologic condition, and Americans.
the meaning of the illness to the person and his or her family). The naturalistic perspective holds that the laws of nature
create imbalances, chaos, and disease. People embracing this
Beliefs About Causes of Illness view use metaphors such as the healing power of nature, and
Throughout history people have tried to understand the they call the earth “Mother.” For example, from the perspec-
cause of illness and disease. Theories of causation have been tive of the Chinese, illness is not seen as an intruding agent
formulated on the basis of ethnic identity, religious beliefs, but as a part of the rhythmic course of life and an outward
social class, philosophic perspectives, and level of knowl- sign of disharmony within.
edge.22 Many people who maintain traditional beliefs would Many Hispanic, Arab, Black, and Asian groups embrace
define Health in terms of balance and a loss of this balance. the hot/cold theory of health and illness, an explanatory
This understanding includes the balance of mind, body, and model with origins in the ancient Greek humoral theory. The
spirit in the overall definitions of Health and Illness. four humors of the body—blood, phlegm, black bile, and
Disease causation may be viewed in three major ways: yellow bile—regulate basic bodily functions and are described
from a biomedical or scientific, a naturalistic or holistic, or a in terms of temperature, dryness, and moisture. The treat-
magicoreligious perspective.21 ment of disease consists of adding or subtracting cold, heat,
dryness, or wetness to restore the balance of the humors.
Biomedical Beverages, foods, herbs, medicines, and diseases are clas-
The first, called the biomedical or scientific theory of illness sified as hot or cold according to their perceived effects on
causation, assumes that all events in life have a cause and the body, not on their physical characteristics. Illnesses
effect, that the human body functions more or less mechani- believed to be caused by cold entering the body include
cally (i.e., the functioning of the human body is analogous to earache, chest cramps, paralysis, gastrointestinal discomfort,
the functioning of an automobile), that all life can be reduced rheumatism, and tuberculosis. Among illnesses believed to be
or divided into smaller parts (e.g., the reduction of the human caused by overheating are abscessed teeth, sore throats, rashes,
person into body, mind, and spirit), and that all of reality can and kidney disorders.
be observed and measured (e.g., intelligence tests and psycho- According to the hot/cold theory, the person is whole, not
metric measures of behavior). Among the biomedical expla- just a particular ailment. Those who embrace the hot/cold
nations for disease is the germ theory, which holds that theory maintain that health consists of a positive state of total
microorganisms such as bacteria and viruses cause specific well-being, including physical, psychological, spiritual, and
disease conditions. Most educational programs for physi- social aspects of the person. Paradoxically the language used
cians, nurses, and other health care providers embrace the to describe this artificial dissection of the body into parts is
biomedical or scientific theories that explain the causes of itself a reflection of the biomedical/scientific perspective, not
both physical and psychological illnesses.20 a naturalistic or holistic one.
Naturalistic Magicoreligious
The second way in which people explain the cause of illness The third major way that people explain the causation of
is from the naturalistic or holistic perspective, found most Illness is from a magicoreligious perspective. The basic
frequently among American Indians, Asians, and others who premise is that the world is an arena in which supernatural
believe that human life is only one aspect of nature and a part forces dominate.14 The fate of the world and those in it
of the general order of the cosmos. These people believe that depends on the action of supernatural forces for good or evil.
the forces of nature must be kept in natural balance or Examples of magical causes of illness include belief in voodoo
harmony. or witchcraft among some Blacks and others from circum-
Some Asians believe in the yin/yang theory, in which Caribbean countries. Faith healing is based on religious beliefs
health exists when all aspects of the person are in perfect and is most prevalent among certain Christian groups,
CHAPTER 2 Cultural Competence 19
TABLE 2-3 Selected Examples of Traditional HEALTH and ILLNESS Beliefs and Practices
HEALTH ILLNESS ILLNESS HEALTH HEALTH HEALTH TRADITIONAL
ORIGIN BELIEFS BELIEFS CAUSATION MAINTENANCE PROTECTION RESTORATION HEALERS
Asian Heritages
China Balance of Imbalance of Upset in the Prevent Wear amulets Traditional Chinese
India “yin and “yin and balance of imbalances of such as jade remedies physicians
Japan yang” yang” “yin and “yin and yang” Eat correct such as Herbalists
Korea yang” and changes in and ginseng root
Philippines Overexertion climate compatible Acupuncture
Southeast Prolonged foods Moxibustion
Asia sitting Cupping
Laos Lying in bed
Cambodia
Vietnam
African Heritages
Africa— Harmony Disharmony Demons Prevent Wear bangles Asafoetida, Root worker
west coast with with nature Evil spirits disharmony; Faith herbs and Spiritualists
(as slaves) nature Voodoo respect roots “Old Lady”
(e.g., Hexes cleanliness
Ghana Religion
Nigeria) Avoid sick
Haiti people
Jamaica
West Indian
islands
European Heritages
England Physical Absence of Evil eye Proper nutrition, Wear amulets Home Homeopathic
France and well-being; Evil spirits exercise, Shawls remedies physicians
Germany emotional feeling bad Hexes cleanliness, such as Brauchers
Poland well-being; and faith in swamp root
Russia feeling God and Olbas
Others okay
DEVELOPMENTAL COMPETENCE
Illness during childhood may pose a difficult clinical situa-
tion. Children and adults have spiritual needs that vary
according to the child’s developmental level and the religious
climate that exists in the family. Parental perceptions about
the illness of the child may be partially influenced by religious
B
beliefs. For example, some parents may believe that a trans-
gression against a religious law is responsible for a congenital
anomaly in their offspring. Other parents may delay seeking
medical care because they believe that prayer should be
tried first. Certain types of treatment (e.g., administration
of blood; medications containing caffeine, pork, or other pro-
hibited substances) and selected procedures may be perceived
as cultural taboos (i.e., practices to be avoided by both
children and adults).
Values held by the dominant U.S. and Canadian cultures
such as emphasis on independence, self-reliance, and produc-
C tivity influence the aging members of society. North Ameri-
cans define people as old at the chronologic age of 65 years
and then limit their work, in contrast to other cultures in
which people are first recognized as being unable to work and
then identified as being “old.” The generation born just before
or at the end of World War II (1940-1949) comprises the early
range of older adults who are eligible for Social Security and
Medicare.
Older persons may develop their own means of coping
with illness through self-care, assistance from family members,
and support from social groups. Some cultures have attitudes
and specific behaviors for older adults that include humanis-
tic care and identification of family members as care provid-
ers. The older adults may have special family responsibilities
(e.g., providing hospitality to visitors [Amish cultures] and
D communicating their skills and accrued wisdom to members
of younger generations [Filipinos]).
2-6 A, The glass blue eye from Turkey seen here is an Older immigrants who have made major lifestyle adjust-
example of an amulet that may be hung in the home. B, A ments in their move from their homelands to the United
seed with a red string may be placed on the crib of a baby States or from a rural to an urban area (or vice versa) may
of Mexican heritage. C, These bangles may be worn for pro- not be aware of health care alternatives, preventive programs,
tection by a person of Caribbean heritage. D, This small health care benefits, and screening programs for which they
packet is placed on a crib or in the room of a baby of Japanese are eligible. These people also may be in various stages of
heritage. (Spector, 2006.)
culture shock (i.e., the state of disorientation or inability to
22 UNIT 1 Assessment of the Whole Person
A C
2-7 A, This “tonic” sold in a botanica is used to treat asthma. B, The traditional medicine bag
of an American Indian shaman is used to carry necessary medicines. C, The leaves in this
package may be used by a person of Chinese heritage to treat indigestion. D, This candle may
be burned for cleansing by a person of Mexican heritage (Spector, 2006).
respond to the behavior of a different cultural group because punishment in Judeo-Christian thought. The meaning of
of its sudden strangeness, unfamiliarity, and incompatibility painful stimuli, the way people define their situations, and
with the newcomer’s perceptions and expectations). For the impact of personal experience all help determine the
example, to maintain ties with their native heritage, people experience of pain.
may purchase food in stores that specialize in selling products In addition to expecting variations in pain perception and
from their homelands. tolerance, you also should expect variations in the expression
of pain. It is well known that people turn to their social
environment for validation and comparison. A first impor-
TRANSCULTURAL EXPRESSION OF PAIN tant comparison group is the family, which transmits cultural
To illustrate how symptom expression may reflect the per- norms to its children.
son’s cultural background, let us use an extensively studied
symptom—pain. Pain is a universally recognized phenome-
non, and it is an important aspect of assessment. It is a
STEPS TO CULTURAL COMPETENCY
private, subjective experience that is greatly influenced by Cultural competency includes the attitudes, knowledge, and
cultural heritage. Expectations, manifestations, and manage- skills necessary for providing quality care to diverse popula-
ment of pain are all embedded in a cultural context. The tions.2,6 You must climb several steps on the journey to cul-
definition of pain, like that of health or illness, is culturally tural competency. The integration of this knowledge into
determined. day-to-day practice takes time because many practitioners in
The word pain is derived from the Greek word for penalty, the health care system hesitate to adopt new ideas. Cultural
which helps explain the long association between pain and competency does not come after reading a chapter or several
CHAPTER 2 Cultural Competence 23
The following set of questions can be used by caregivers to begin to determine a person’s ethnic, cultural, or religious heritage
and its relationship to his or her personal and health care traditions. The stronger the association of these items to a person’s
identification, the more traditional is his or her heritage.
From Spector, R. E. (2013). Cultural diversity in health and illness (8th ed.). Upper Saddle River, NJ: Pearson, pp. 376-378.
2-8
24 UNIT 1 Assessment of the Whole Person
chapters or books on this highly specialized area. It is complex issues in the context of culture. The model has five catego-
and multifaceted, and many facets change over time. The ries: cultural identity of the individual, cultural explanation
areas of knowledge include sociology, psychology, theology, of the individual’s illness, cultural factors related to psy
cultural anthropology, demography, folklore, and immigra- chosocial environment and levels of functioning, and cul-
tion history and policies. One must also have an understand- tural elements of the relationship between the individual
ing of poverty and environmental health. Cultural competency and the clinician. This assessment tool provides an overall
also involves soul searching about your own culture and cultural assessment to promote culturally competent diag-
health. nosis and care.
One response to the government mandates for cultural
competency is the development of cultural care that describes Heritage Assessment
professional health care as culturally sensitive, appropriate, The following are the factors of heritage consistency that
and competent. There is a discrete body of knowledge, and determine the depth to which you and the given patient iden-
much of the content is introduced in this chapter. tify with a traditional heritage (i.e., the cultural beliefs and
• Culturally sensitive implies that caregivers possess some practices of the family, the extended family, and an ethnore-
basic knowledge of and constructive attitudes toward ligious community).
the diverse cultural populations found in the setting in The Heritage Assessment tool (Fig. 2-8), lists all of the
which they are practicing. questions that may be asked. It is important to ask the ques-
• Culturally appropriate implies that the caregivers apply tions slowly over time. If the person appears anxious, it is best
the underlying background knowledge that must be to postpone asking the questions or to weave them into other
possessed to provide a given person with the best pos- parts of the health history. The responses can be scored, and
sible health care. an image arises as to whether the person identifies with his
• Culturally competent implies that the caregivers under- or her traditional heritage or whether he or she is accultur-
stand and attend to the total context of the individual’s ated and assimilated into the mainstream of modern Ameri-
situation, including awareness of immigration status, can culture.
stress factors, other social factors, and cultural similari- In addition to the background information, four short
ties and differences.39 questions may be asked:
Cultural care is the provision of health care across cultural 1. Do you mostly participate in social activities with
boundaries and considers the context both in which the members of your family?
patient lives and the situations in which the patient’s health 2. Do you mostly have friends from a similar cultural
problems arise.41 Each chapter in this text includes informa- background as you?
tion necessary for delivery of cultural care. 3. Do you mostly eat the foods of your family’s
tradition?
CULTURAL ASSESSMENT 4. Do you mostly participate in the religious traditions of
your family?
Cultural Formulation Model If the person answers two to four of these questions positively,
The Cultural Formulation Model24 is a well-recognized tool the probability of being more likely to use health practices
to use to provide an in-depth exploration of the patient’s relevant to their traditional heritage is high.
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Repeat the same procedure the next day. Vary the introduction
somewhat, like this: “I want you to do this just as you did yesterday,
except that I want this margin over here on the right side to be on a
straight line. Wait till I take this ruler and show you.” Lay the ruler
lengthwise of the sheet you want the pupil to write on, so that you
can take your lead pencil and make a line about an inch from the
right side of the page. “Now, when you have written out to this line
here, then stop and begin on the next line like this:” (show the child
how you write a sentence and begin on the next line). It would be
well if the sentence which you use as an example were to be one that
would express some familiar thought about the child’s immediate
interests, such as his favorite sport. Leave the child’s desk as you
were advised to leave it the day before and also return as before and
approve that which the pupil does well, either saying absolutely
nothing about the careless parts or suggest incidently that the pupil
could help such and such a part by doing this or that thing to it. Be
sure to end your remarks by some such expression as, “That’s good,”
or “That’s fine.”
(3) Learning to Draw. Not infrequently it Lower Grades
happens that a pupil comes into school who
has never learned to draw and who, feeling his inability to
accomplish the task set for him in the drawing lesson, refuses to
make any attempt to do so. Especially is this true if the picture is to
be drawn from imagination. In such a case it is best to begin with
copying. When this art is learned, drawing from imagination will be a
comparatively easy step.
For example, choose a very simple picture for the child to
reproduce on another piece of paper. It is a good plan for a teacher to
have at least a dozen or more pictures in one drawer of his desk all
the time, because many pupils like to draw and copy pictures and it
is an excellent way to get them interested in other work. Present the
picture of some ordinary scene. Tell the pupil before he begins that
you are going to make a collection of pictures which your pupils
draw. The picture need not have much life in it to start with, but right
here we make use of the child’s imagination to wonderful advantage.
Suppose the picture, which you have in hand, shows a tree or two, a
house, a couple of bushes or any kind of natural objects whatsoever.
Talk to the pupil in this fashion, pointing to different parts of the
picture with your pencil and have your face near the picture,
indicating interest and enthusiasm as you talk: “Now, right behind
this tree here, I want you to draw a boy, sticking his head out from
behind the tree. And right over here, where I make this little cross
mark, I want you to draw a little girl hiding behind this bush. We will
suppose they are playing ‘Hide and Seek.’ Right over here, between
this tree and the house, draw a boy’s hat. Maybe he has lost it while
he was running to hide. You know how to make a hat. Just like this:”
(draw a very simple hat, merely making a straight line and a semi-
circle connecting two points in it.) “Maybe you can draw a better one
than that. I’ll come back to your desk pretty soon and see what kind
of a hat you drew and also that little boy sticking his head out from
behind the tree. Is your pencil sharp enough?”
The child will say that his pencil is all right. Then leave him at once
and in ten or fifteen minutes return. Go back with this one thought in
mind, that you will say nothing at all except that which is
complimentary. For example, say, “Well, I should say you can draw. I
believe you made a better hat than I did. Now this afternoon, I am
going to give you something else to draw. Maybe a pony with a boy
on his back and a girl riding in the pony cart. You are going to be
good at drawing things for me, I know. I want to keep all of your
drawings after you have finished them for me.”
In case the child should interrupt and ask to draw the pony right
away instead of waiting until afternoon, answer by saying, “I will
have the picture ready for you after dinner and then I will bring it to
you.”
Of course, it is not necessary to use the exact words we have
suggested, or to use the same pictures or even to use pictures at all.
The important point is to offer something that is at once interesting
in order to get the pupil started in drawing. Do not insist much upon
regular lessons during the first day or two in which your chief
problem is to get the pupil’s confidence.
After the child has learned to like to do the things which you
suggest present more difficult, or even purely imaginative, subjects
for drawing.
Use the same method in getting the child to take an interest in
other subjects than drawing—that is, give him very small tasks, then
approve and compliment him on his ability. This will bring good
results with any pupil who is normal.
As a transition step between mere copying and drawing wholly
from the imagination, and also to give the timid child confidence
enough to come to the blackboard to draw in the presence of other
children, the following might be tried.
Having the confidence of the little pupil, go to his desk just before
school closes in the evening and say, “I would like for you to stay just
a moment after school. I want to tell you something.”
After most of the pupils have marched out, return to his desk,
begin to talk enthusiastically about a picture which you have. Tell
him to follow you and you will try to draw it. Then after reaching the
blackboard and picking up a piece of crayon, say, “Now, I am going
to draw this man’s face and I want you to draw his eyes.” Let it take
you about a minute to draw the outline of the man’s face, talking all
the time about how well you like to draw pictures, then say, “Now
let’s see if you can draw his eyes. Make a mark right there” (point to a
spot). “Good! Now draw his other eye. Good! Now his ear. Make a
mark right here” (point to a spot). “My, that’s fine. See, what a fine
man you drew.” Start to leave the blackboard and say, “I’m going to
have you draw for me again.”
Repeat this process every day until you feel sure that the child will
go to the blackboard and work in the presence of yourself and the
class.
DIVISION VII
Only through the gateway of personal experience does the child enter into the
larger understanding of the thought and achievement of humanity.
CASES ARISING OUT OF THE SOCIAL
INSTINCTS
CONSTRUCTIVE TREATMENT
There are occasions when a definite issue for the mastery occurs in
the school-room, and this was one of them. Miss Nelson had no right
to break her promise to a docile and obedient child, and reinforce the
habitual selfishness of a spoiled one. She should have insisted that
Karen take her turn with the rest, and if Karen had stormed it would
have given her a good opportunity to show her that her usual
methods would not work in school. The angry storming of a spoiled
child is usually done with an alert eye to the effect produced on the
audience; therefore, if Karen had wept and wailed, she should have
been carried out into the hall, where she might have been left in
lonely state to recover her good temper. Usually one or two such
trials convince a spoiled child that he has met his match, and if such
children are followed by tactful guidance, and especially if attention
can be diverted away from themselves, the worst-spoiled children
can in time be thoroughly socialized.
COMMENTS
ILLUSTRATION (KINDERGARTEN)
CONSTRUCTIVE TREATMENT
When children are not supplied with the necessary equipment for
their work and are too poor to buy for themselves make an appeal to
the board of education asking them to purchase the material needed,
which material should be considered the property of the school and
left there from year to year. Most states require that the school
furnish books and equipment for all who are unable to buy them.
Show by your own example that poor people are just as desirable
for companions as rich ones, other things being equal. See to it that
the children of poor parents be made to forget, while at school, that
they are different from others. See to it that democracy reigns on the
playground.
Supervise all play.
Do not foster the borrowing habit.
COMMENTS
CONSTRUCTIVE TREATMENT
Miss Bush was too superficial in her original treatment of this case.
She had had ample time to think out a workable plan that would
have caused no friction.
After having all food removed from the desks she might have asked
the pupils to find appropriate seats in which to eat their lunches.
After lunch time she should have led the way to the playground
where all else than play would be easily forgotten.
From time to time short talks on manners should be given to the
whole school.
COMMENTS