HA-RLE-WS # 8 Assessing Culture

Worksheet 8
Assessing Culture
Case Study
Read the following case study. Then, work through the steps of analyzing the case study data.
1. First, identify the abnormal data and strengths in subjective and objective findings,
2. Assemble cue clusters,
3. Draw inferences,
4. Make possible nursing diagnoses,
5. Identify defining characteristics,
6. Confirm or rule out the diagnoses, and
7. Document your conclusions.
Use the table below to collect subjective and objective date provided to guide you. Propose nursing
diagnoses that are specific to the client in the case study. Identify collaborative problems, if any, for this
client. Finally identify data, if any, which point toward a medical problem requiring a referral.
Case Study
A female patient in her mid-40's comes into the hospital screaming while holding her abdomen.
She cannot speak any English. Jane RN asks the patient her name. She replies, "Marie. Jane RN asks the
patient her last name. She again replied, "Maria". Jane RN and her patient went through this over and
over. Jane RN could not speak any Spanish and the patient could not speak any English. After several
minutes of her holding her abdomen and yelling at the Jane RN in Spanish, The RN got out the over-the-
phone interpreter. Jane RN was then connected to a nice lady who interpreted everything she said. The
interpreter was very calming to the patient. Jane RN learned her patient's name and that she had been
having horrible abdominal pain for 2 days. After doing some tests, we found that she had appendicitis.
She was very afraid and had a lot of questions. We again communicated with the over-the-phone
interpreter. Jane RN learned a lot about her patient and her culture and the RN felt that she bonded
with her patient. Since that patient, Jane RN has had several more Hispanic patients. She has learned
that Hispanic women often express their pain loudly. Jane RN has seen other nurses that she works with
become very annoyed at the way Hispanics vocalize their pain. It is important not to generalize the way
patients should express themselves. We must accept them and become familiar with their culture.
Note: Please secure consent before starting the interview to actual client….
NURSING INTERVIEW GUIDE TO COLLECT SUBJECTIVE DATA

QUESTIONS FINDINGS
Biographical Data
Name (use Code Name or Alyas) Marie
Gender Female
Address, Phone Number Spain
Date and Place of Birth NA
Nationality or Ethnicity Spanish
Marital Status NA
Religious or Spiritual Practices NA
Primary and Secondary Languages spoken, written, NA

and read; Birth Language
Educational Level NA
Occupation and Working Status NA
Who lives with the client? Identify significant others NA

Caregivers and support people for the client NA
Current Symptoms (Ask Client)

1. What has brought you to the clinic today? NA
2. What do you believe has caused this illness? NA
3. What have you done to treat it? Are there family NA

remedies that you usually use for this illness? Have
they worked for other family members of for you in
the past?
4. What do you believe that health care providers can NA

do that will help you?
5. Are you taking any medications? Do you have NA

allergies or reactions to any medications or foods?
Affect and Behaviors (Observed)
1. Does affect corresponds to verbal expressions? Yes
2. Does pattern of eye contact correspond to the Yes

client’s culture or to the majority culture?
3. Does the client divulge information readily or with NA

reluctance?
4. Does the client seem to accept you (gender, age) as Yes

a caregiver?
5. Does space appear to be an issue with the client? No
6. Are there any other communication patterns that Yes

seem to be relevant to this interview?
Past Health History

1. What has been your experience with health care NA
professionals in the past?
2. Have you used community caregivers? NA
3. Have you had any illnesses like this one before? NA
4. Do you have or have you experienced any other The nurse learned her patient had been having
illnesses in the past? horrible pain for 2 days.
5. what types of illnesses have gotten you to go to a NA
doctor or nurse in the past?
Family History
1. How many family members live in the community? NA
In the household?
2. Are the family members healthy? Have illnesses? NA

Able to provide support to you?
Lifestyle and Health Practices

1. Do you believe that exercise is important to NA
health?
2. Do you smoke? Drink alcohol? If yes, how No

much or how often?
3. Do you participate in religious practices? Do NA

your beliefs and practices provide strength
and comfort? Are they essential to your well-
being?
4. Do you have beliefs that would conflict with NA

treatments or procedures?
5. What type of diet do you eat? Is it restricted NA

in any way by religious or cultural beliefs?
Are there foods that you can believe help to
make you healthy? Ill?
Analysis
Formulate nursing diagnoses Acute pain related to obstructed appendix. Risk for
deficient fluid volume related to preoperative
vomiting, postoperative restrictions. Risk for infection
related to ruptured appendix.
Formulate collaborative problems The nurse reefers the patient to her physician to
perform appendicitis treatment which involves surgery
to remove the inflamed appendix.

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Worksheet 8

NURSING INTERVIEW GUIDE TO COLLECT SUBJECTIVE DATA

Address, Phone Number Spain

Date and Place of Birth NA

Nationality or Ethnicity Spanish

Religious or Spiritual Practices NA

Primary and Secondary Languages spoken, written, NA

Occupation and Working Status NA

Who lives with the client? Identify significant others NA

Current Symptoms (Ask Client)

2. What do you believe has caused this illness? NA

3. What have you done to treat it? Are there family NA

4. What do you believe that health care providers can NA

5. Are you taking any medications? Do you have NA

2. Does pattern of eye contact correspond to the Yes

3. Does the client divulge information readily or with NA

4. Does the client seem to accept you (gender, age) as Yes

5. Does space appear to be an issue with the client? No

6. Are there any other communication patterns that Yes

Past Health History

2. Have you used community caregivers? NA

3. Have you had any illnesses like this one before? NA

2. Are the family members healthy? Have illnesses? NA

Lifestyle and Health Practices

2. Do you smoke? Drink alcohol? If yes, how No

3. Do you participate in religious practices? Do NA

4. Do you have beliefs that would conflict with NA

5. What type of diet do you eat? Is it restricted NA

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