Physical Examination and Health Assessment (Carolyn Jarvis) (z-lib.org).pdf

Physical Examination & Health Assessment
8TH EDITION
CAROLYN JARVIS, PhD, APRN, CNP
Professor of Nursing
Illinois Wesleyan University
Bloomington, Illinois
and
Family Nurse Practitioner
With Ann Eckhardt, PhD, RN
Associate Professor of Nursing
Original Illustrations by Pat Thomas, CMI, FAMI
East Troy, Wisconsin
2

Table of Contents
Cover image
Title Page
Chapter Organization
Structure and Function
Subjective Data
Objective Data
Health Promotion and Patient Teaching
Documentation and Critical Thinking
Abnormal Findings
Copyright
Dedication
About the Author
Contributors
Reviewers
Preface
Acknowledgments
Unit 1 Assessment of the Whole Person
Chapter 1 Evidence-Based Assessment
Culture and Genetics
References
Chapter 2 Cultural Assessment
Developmental Competence
3

References
Chapter 3 The Interview
References
Chapter 4 The Complete Health History
References
Chapter 5 Mental Status Assessment
Objective Data
Documentation And Critical Thinking
Abnormal Findings
Abnormal Findings for Advanced Practice
Summary Checklist: Mental Status Assessment
References
Chapter 6 Substance Use Assessment
Subjective Data
Objective Data
Abnormal Findings
Bibliography
Chapter 7 Domestic and Family Violence Assessment
Subjective Data
Objective Data
Abnormal Findings
References
Unit 2 Approach to the Clinical Setting
4

Chapter 8 Assessment Techniques and Safety in the Clinical Setting
References
Chapter 9 General Survey and Measurement
Objective Data
Abnormal Findings
References
Chapter 10 Vital Signs
Objective Data
Abnormal Findings
References
Chapter 11 Pain Assessment
Subjective Data
Objective Data
Abnormal Findings
References
Chapter 12 Nutrition Assessment
Subjective Data
Objective Data
Abnormal Findings
Summary Checklist: Nutritional Assessment
References
5

Unit 3 Physical Examination
Chapter 13 Skin, Hair, and Nails
Subjective Data
Objective Data
Abnormal Findings
Summary Checklist: Skin, Hair, and Nails Examination
References
Chapter 14 Head, Face, Neck, and Regional Lymphatics
Subjective Data
Objective Data
Abnormal Findings
Summary Checklist: Head, Face, and Neck, Including Regional Lymphatics Examination
References
Chapter 15 Eyes
Subjective Data
Objective Data
Abnormal Findings
Summary Checklist: Eye Examination
References
6

Chapter 16 Ears
Subjective Data
Objective Data
Abnormal Findings
Summary Checklist: Ear Examination
References
Chapter 17 Nose, Mouth, and Throat
Subjective Data
Objective Data
Abnormal Findings
References
Chapter 18 Breasts, Axillae, and Regional Lymphatics
Objective Data
Abnormal Findings
Summary Checklist: Breasts and Regional Lymphatics Examination
References
Chapter 19 Thorax and Lungs
Subjective Data
7

Objective Data
Abnormal Findings
Summary Checklist: Thorax and Lung Examination
References
Chapter 20 Heart and Neck Vessels
Subjective Data
Objective Data
Abnormal Findings
Summary Checklist: Heart and Neck Vessels Examination
References
Chapter 21 Peripheral Vascular System and Lymphatic System
Subjective Data
Objective Data
Abnormal Findings
Summary Checklist: Peripheral Vascular Examination
References
Chapter 22 Abdomen
Subjective Data
Objective Data
8

Abnormal Findings
Summary Checklist: Abdomen Examination
References
Chapter 23 Musculoskeletal System
Subjective Data
Objective Data
Summary Checklist: Musculoskeletal Examination
References
Chapter 24 Neurologic System
Subjective Data
Objective Data
Abnormal Findings
Summary Checklist: Neurologic Examination
References
Chapter 25 Male Genitourinary System
Subjective Data
Objective Data
9

Abnormal Findings
Summary Checklist: Male Genitalia Examination
References
Chapter 26 Anus, Rectum, and Prostate
Subjective Data
Objective Data
Abnormal Findings
Summary Checklist: Anus, Rectum, and Prostate Examination
References
Chapter 27 Female Genitourinary System
Subjective Data
Objective Data
Summary Checklist: Female Genitalia Examination
References
Unit 4 Integration: Putting It All Together
Chapter 28 The Complete Health Assessment
Chapter 29 The Complete Physical Assessment
Sequence/Selected Photos
10

Chapter 30 Bedside Assessment and Electronic Documentation
Sequence/Selected Photos
References
Chapter 31 The Pregnant Woman
Subjective Data
Objective Data
Summary Checklist: The Pregnant Woman
References
Chapter 32 Functional Assessment of the Older Adult
References
Illustration Credits
Index
Assessment Terms: English and Spanish
Assessment Terms: English and Spanish
11

Chapter Organization
The following color bars are used consistently for each section within a chapter to help locate
specific information.
12

Anatomy and physiology by body system
13

Subjective Data
Health history through questions (examiner asks) and explanation (rationale)
14

Objective 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
15

Health promotion related to each body system.
16

Clinical case studies with sample documentation for subjective, objective, and assessment data
17

Abnormal Findings
Tables of art and photographs of pathologic disorders and conditions; abnormal findings for clinical
practice and advanced practice where appropriate
18

Copyright
PHYSICAL EXAMINATION AND HEALTH ASSESSMENT, EIGHTH EDITION ISBN: 978-0-323-
51080-6
Copyright © 2020 by Elsevier Inc. All rights reserved.
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 Publisher's permissions policies and our arrangements
with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency,
can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).
Notice
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds or experiments described herein.
Because of rapid advances in the medical sciences, in particular, independent verification of
diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is
assumed by Elsevier, authors, editors or contributors 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.
Previous editions copyrighted 2016, 2012, 2008, 2004, 2000, 1996, 1993.
International Standard Book Number: 978-0-323-51080-6
Executive Content Strategist: Lee Henderson
Senior Content Development Specialist: Heather Bays
Publishing Services Manager: Julie Eddy
Senior Project Manager: Jodi M. Willard
Design Direction: Brian Salisbury
Printed in Canada
Last digit is the print number: 9 8 7 6 5 4 3 2 1
3251 Riverport Lane
St. Louis, Missouri 63043
19

Dedication
To Paul, with love and thanks. You have read every word.
21

About the Author
Carolyn Jarvis received her PhD from the University of Illinois at Chicago, with a research
interest in the physiologic effect of alcohol on the cardiovascular system; her MSN from Loyola
University (Chicago); and her BSN cum laude from the University of Iowa. She is Professor, School
of Nursing at Illinois Wesleyan University, where she teaches Health Assessment, Pathophysiology,
and Pharmacology. Dr. Jarvis has taught physical assessment and critical care nursing at Rush
University (Chicago), the University of Missouri (Columbia), and the University of Illinois
(Urbana). Her current research interest concerns alcohol-interactive medications, and she includes
Honors students in this research.
In 2016, Illinois Wesleyan University honored Dr. Jarvis for her contributions to the ever-
changing field of nursing with the dedication of the Jarvis Center for Nursing Excellence. The Jarvis
Center for Nursing Excellence equips students with laboratory and simulation learning so that they
may pursue their nursing career with the same commitment as Dr. Jarvis.
Dr. Jarvis is the Student Senate Professor of the Year (2017) and was honored to give remarks at
commencement. She is a recipient of the University of Missouri's Superior Teaching Award; has
taught physical assessment to thousands of baccalaureate students, graduate students, and nursing
professionals; has held 150 continuing education seminars; and is the author of numerous articles
and textbook contributions.
Dr. Jarvis has maintained a clinical practice in advanced practice roles—first as a cardiovascular
clinical specialist in various critical care settings and as a certified family nurse practitioner in
primary care. During the last 12 years, her enthusiasm has focused on Spanish language skills to
provide health care in rural Guatemala and at the Community Health Care Clinic in Bloomington.
Dr. Jarvis has been instrumental in developing a synchronous teaching program for Illinois
Wesleyan students both in Barcelona, Spain, and at the home campus.
22

Contributors
CHAPTER CONTRIBUTOR
Lydia Bertschi DNP, APRN, ACNP-BC
The co-contributor for Chapter 22 (Abdomen), Dr. Bertschi is an Assistant Professor at Illinois
Wesleyan University School of Nursing and a nurse practitioner in the intensive care unit at
UnityPoint Health—Methodist.
ASSESSMENT PHOTOGRAPHERS
Chandi Kessler BSN, RN
Chandi is a former Intensive Care Unit nurse and is an award-winning professional photographer.
Chandi specializes in newborn and family photography in and around Central Illinois.
Kevin Strandberg
Kevin is a Professor of Art Emeritus at Illinois Wesleyan University in Bloomington, Illinois. He has
contributed to all editions of Physical Examination & Health Assessment.
INSTRUCTOR AND STUDENT ANCILLARIES
Case Studies
Melissa M. Vander Stucken MSN, RN
Clinical Assistant Professor
School of Nursing
Sam Houston State University
Huntsville, Texas
Key Points
Joanna Cain BSN, BA, RN
Auctorial Pursuits, Inc.
President and Founder
Boulder, Colorado
PowerPoint Presentations
Daryle Wane PhD, ARNP, FNP-BC
BSN Program Director—Professor of Nursing
Department of Nursing and Health Programs
Pasco-Hernando State College
New Port Richey, Florida
Review Questions
Kelly K. Zinn PhD, RN
Associate Professor
School of Nursing
Huntsville, Texas
TEACH for Nurses
Jennifer Duke
Freelancer
St. Louis, Missouri
Test Bank
24

Heidi Monroe MSN, RN-BC, CAPA
Assistant Professor of Nursing
NCLEX-RN Coordinator
Bellin College
Green Bay, Wisconsin
Test Bank Review
Associate Professor
School of Nursing
Huntsville, Texas
25

Reviewers
Valerie J. Fuller PhD, DNP, AGACNP-BC, FNP-BC, FAANP, FNAP
Assistant Professor
School of Nursing
University of Southern Maine
Portland, Maine
Peggy J. Jacobs DNP, RNC-OB, CNM, APRN
Instructional Support and Outcomes Coordinator
School of Nursing
Marie Kelly Lindley PhD, RN
Louise Herrington School of Nursing
Baylor University
Dallas, Texas
Jeanne Wood Mann PhD, MSN, RN, CNE
Assistant Dean;
Associate Professor
School of Nursing
Baker University
Topeka, Kansas
Judy Nelson RN, MSN
Nurse Educator
Nursing
Fort Scott Community College
Fort Scott, Kansas
Cheryl A. Tucker DNP, RN, CNE
Clinical Associate Professor;
Undergraduate Level II BSN Coordinator
Louise Herrington School of Nursing
Baylor University
Dallas, Texas
Melissa M. Vander Stucken MSN, RN
School of Nursing
Huntsville, Texas
Associate Professor
School of Nursing
Huntsville, Texas
26

Preface
This book is for those who still carefully examine their patients and for those of you who wish to
learn how to do so. You develop and practice, and then learn to trust, your health history and
physical examination skills. In this book, we give you the tools to do that. Learn to listen to the
patient—most often he or she will tell you what is wrong (and right) and what you can do to meet
his or her health care needs. Then learn to inspect, examine, and listen to the person's body. The
data are all there and are accessible to you by using just a few extra tools. High-tech machinery is a
smart and sophisticated adjunct, but it cannot replace your own bedside assessment of your patient.
Whether you are a beginning examiner or an advanced-practice student, this book holds the content
you need to develop and refine your clinical skills.
This is a readable college text. All 8 editions have had these strengths: a clear, approachable
writing style; an attractive and user-friendly format; integrated developmental variations across the
life span with age-specific content on the infant, child, adolescent, pregnant woman, and older
adult; cultural competencies in both a separate chapter and throughout the book; hundreds of
meticulously prepared full-color illustrations; sample documentation of normal and abnormal
findings and 60 clinical case studies; integration of the complete health assessment in 2 photo essays
at the end of the book, where all key steps of a complete head-to-toe examination of the adult,
infant, and child are summarized; and a photo essay highlighting a condensed head-to-toe
assessment for each daily segment of patient care.
New to the Eighth Edition
The 8th edition has a new chapter section and several new content features. Cultural Assessment
in Chapter 2 is rewritten to increase emphasis on cultural assessment, self-assessment, and a new
section on spiritual assessment. The Interview in Chapter 3 has a new section on interprofessional
communication; Mental Status Assessment in Chapter 5 now includes the Montreal Cognitive
Assessment; Substance Use Assessment in Chapter 6 includes additional content on opioid/heroin
epidemic and alcohol-interactive medications; Domestic and Family Violence Assessment in
Chapter 7 includes all new photos, updates on the health effects of violence, added information on
the health effects of violence, and additional content on child abuse and elder abuse. The former
Vital Signs and Measurement chapter is now split into 2 chapters to increase readability; the Vital
Signs chapter (Chapter 10) stands alone with updated information on blood pressure guidelines.
The Physical Examination chapters all have a new feature—Health Promotion and Patient
Teaching—to give the reader current teaching guidelines. Many chapters have all new exam photos
for a fresh and accurate look. The focus throughout is evidence-based practice. Examination
techniques are explained and included (and in some cases, rejected) depending on current clinical
evidence.
Pat Thomas has designed 15 new art pieces in beautiful detail and 30 photo overlays. We have
worked together to design new chapter openers and anatomy; note Fig. 11.4 on opioid targets, Figs.
14.1 and 14.2 on complex anatomy of skull and facial muscles, Fig. 15.5 on complex eye anatomy;
Fig 23.8 on 3 images of complex shoulder anatomy showing muscle girdle, Fig. 27.2 on complex
female internal anatomy, and many others. We have worked with Chandi Kesler and Kevin
Strandberg in new photo shoots, replacing exam photos in Chapters 6 (Substance Use Assessment),
23 (Musculoskeletal System), 24 (Neurologic System), 28 (The Complete Health Assessment: Adult),
and many others.
All physical examination chapters are revised and updated, with evidence-based data in
anatomy and physiology, physical examination, and assessment tools. Developmental Competence
sections provide updated common illnesses, growth and development information, and the
Examination section of each body system chapter details exam techniques and clinical findings for
infants, children, adolescents, and older adults.
Culture and Genetics data have been revised and updated in each chapter. Common illnesses
28

affecting diverse groups are detailed. We know that some groups suffer an undue burden of some
diseases, not because of racial diversity per se, but because these groups are overrepresented in the
uninsured/poverty ranks and lack access to quality health care.
The Abnormal Findings tables located at the end of the chapters are revised and updated with
many new clinical photos. These are still divided into two sections. The Abnormal Findings tables
present frequently encountered conditions that every clinician should recognize, and the Abnormal
Findings for Advanced Practice tables isolate the detailed illustrated atlas of conditions encountered
in advanced practice roles.
Chapter references are up-to-date and are meant to be used. They include the best of clinical
practice readings as well as basic science research and nursing research, with an emphasis on
scholarship from the last 5 years.
Dual Focus as Text and Reference
Physical Examination & Health Assessment is a text for beginning students of physical examination as
well as a text and reference for advanced practitioners. The chapter progression and format permit
this scope without sacrificing one use for the other.
Chapters 1 through 7 focus on health assessment of the whole person, including health
promotion for all age-groups, cultural environment and assessment, interviewing and complete
health history gathering, the social environment of mental status, and the changes to the whole
person on the occasions of substance use or domestic violence.
Chapters 8 through 12 begin the approach to the clinical care setting, describing physical data-
gathering techniques, how to set up the examination site, body measurement and vital signs, pain
assessment, and nutritional assessment.
Chapters 13 through 27 focus on the physical examination and related health history in a body
systems approach. This is the most efficient method of performing the examination and is the most
logical method for student learning and retrieval of data. Both the novice and the advanced
practitioner can review anatomy and physiology; learn the skills, expected findings, and common
variations for generally healthy people; and study a comprehensive atlas of abnormal findings.
Chapters 28 through 32 integrate the complete health assessment. Chapters 28, 29 and 30
present the choreography of the head-to-toe exam for a complete screening examination in various
age-groups and for the focused exam in this unique chapter on a hospitalized adult. Chapters 31
and 32 present special populations—the assessment of the pregnant woman and the functional
assessment of the older adult, including assessment tools and caregiver and environmental
assessment.
This text is valuable to both advanced practice students and experienced clinicians because of its
comprehensive approach. Physical Examination & Health Assessment can help clinicians learn the
skills for advanced practice, refresh their memory, review a specific examination technique when
confronted with an unfamiliar clinical situation, compare and label a diagnostic finding, and study
the Abnormal Findings for Advanced Practice.
Continuing Features
1. Method of examination (Objective Data section) is clear, orderly, and easy to follow.
Hundreds of original examination illustrations are placed directly with the text to
demonstrate the physical examination in a step-by-step format.
2. Two-column format begins in the Subjective Data section, where the running column
highlights the rationales for asking history questions. In the Objective Data section, the
running column highlights selected abnormal findings to show a clear relationship between
normal and abnormal findings.
3. Abnormal Findings tables organize and expand on material in the examination section.
The atlas format of these extensive collections of pathology and original illustrations helps
students recognize, sort, and describe abnormal findings.
4. Genetics and cultural variations in disease incidence and response to treatment are cited
throughout using current evidence. The Jarvis text has the richest amount of cultural-
genetic content available in any assessment text.
5. Developmental approach in each chapter presents a prototype for the adult, then age-
29

specific content for the infant, child, adolescent, pregnant female, and older adult so
students can learn common variations for all age-groups.
6. Stunning full-color art shows detailed human anatomy, physiology, examination
techniques, and abnormal findings.
7. Health history (Subjective Data) appears in two places: (1) in Chapter 4, The Complete
Health History; and (2) in pertinent history questions that are repeated and expanded in
each regional examination chapter, including history questions that highlight health
promotion and self-care. This presentation helps students understand the relationship
between subjective and objective data. Considering the history and examination data
together, as you do in the clinical setting, means that each chapter can stand on its own if a
person has a specific problem related to that body system.
8. Chapter 3, The Interview, has the most complete discussion available on the process of
communication, interviewing skills, techniques and traps, and cultural considerations (for
example, how nonverbal behavior varies cross-culturally and the use of an interpreter).
9. Summary checklists at the end of each chapter provide a quick review of examination steps
to help develop a mental checklist.
10. Sample recordings of normal and abnormal findings show the written language you
should use so that documentation, whether written or electronic, is complete yet succinct.
11. 60 Clinical Case Studies of frequently encountered situations that show the application of
assessment techniques to patients of varying ages and clinical situations. These case
histories, in SOAP format ending in diagnosis, use the actual language of recording. We
encourage professors and students to use these as critical thinking exercises to discuss and
develop a Plan for each one.
11. User-friendly design makes the book easy to use. Frequent subheadings and instructional
headings assist in easy retrieval of material.
12. Spanish-language translations highlight important phrases for communication during the
physical examination and appear on the inside back cover.
Supplements
• The Pocket Companion for Physical Examination & Health
Assessment continues to be a handy and current clinical reference
that provides pertinent material in full color, with over 200
illustrations from the textbook.
• The Study Guide & Laboratory Manual with physical
examination forms is a full-color workbook that includes for each
chapter a student study guide, glossary of key terms, clinical
objectives, regional write-up forms, and review questions. The
pages are perforated so students can use the regional write-up
forms in the skills laboratory or in the clinical setting and turn
them in to the instructor.
• The revised Health Assessment Online is an innovative and
dynamic teaching and learning tool with more than 8000
electronic assets, including video clips, anatomic overlays,
animations, audio clips, interactive exercises, laboratory/diagnostic
tests, review questions, and electronic charting activities.
Comprehensive Self-Paced Learning Modules offer increased
flexibility to faculty who wish to provide students with tutorial
learning modules and in-depth capstone case studies for each
30

body system chapter in the text. The Capstone Case Studies
include Quality and Safety Challenge activities. Additional
Advance Practice Case Studies put the student in the exam room
and test history-taking and documentation skills. The
comprehensive video clip library shows exam procedures across
the life span, including clips on the pregnant woman. Animations,
sounds, images, interactive activities, and video clips are
embedded in the learning modules and cases to provide a
dynamic, multimodal learning environment for today's learners.
• The companion EVOLVE Website
(http://evolve.elsevier.com/Jarvis/) for students and instructors
contains learning objectives, more than 300 multiple-choice and
alternate-format review questions, printable key points from the
chapter, and a comprehensive physical exam form for the adult.
Case studies—including a variety of developmental and cultural
variables—help students apply health assessment skills and
knowledge. These include 25 in-depth case studies with critical
thinking questions and answer guidelines. Also included is a
complete Head-to-Toe Video Examination of the Adult that can be
viewed in its entirety or by systems.
• Simulation Learning System. The new Simulation Learning
System (SLS) is an online toolkit that incorporates medium- to
high-fidelity simulation with scenarios that enhance the clinical
decision-making skills of students. The SLS offers a comprehensive
package of resources, including leveled patient scenarios, detailed
instructions for preparation and implementation of the simulation
experience, debriefing questions that encourage critical thinking,
and learning resources to reinforce student comprehension.
• For instructors, the Evolve website presents TEACH for Nursing,
PowerPoint slides, a comprehensive Image Collection, and a Test
Bank. TEACH for Nurses provides annotated learning objectives,
key terms, teaching strategies for the classroom in a revised section
with strategies for both clinical and simulation lab use and a focus
on QSEN competencies, critical thinking exercises, websites, and
performance checklists. The PowerPoint slides include 2000 slides
with integrated images and Audience Response Questions. A
separate 1200-illustration Image Collection is featured and,
finally, the ExamView Test Bank has over 1000 multiple-choice
and alternate-format questions with coded answers and rationales.
In Conclusion
31

Throughout all stages of manuscript preparation and production, we make every effort to develop a
book that is readable, informative, instructive, and vital. Thank you for your enthusiastic response
to the earlier editions of Physical Examination & Health Assessment. I am grateful for your
encouragement and for your suggestions, which are incorporated wherever possible. Your
comments and suggestions continue to be welcome for this edition.
Carolyn Jarvis c/o Education Content Elsevier 3251 Riverport Lane Maryland Heights, MO 63043
32

Acknowledgments
These 8 editions have been a labor of love and scholarship. During the 38 years of writing these
texts, I have been buoyed by the many talented and dedicated colleagues who helped make the
revisions possible.
Thank you to the bright, hardworking professional team at Elsevier. I am fortunate to have the
support of Lee Henderson, Executive Content Strategist. Lee coordinates communication with
Marketing and Sales and helps integrate user comments into the overall plan. I am grateful to work
daily with Heather Bays, Senior Content Development Specialist. Heather juggled all the deadlines,
readied all the manuscript for production, searched out endless photos for abnormal examination
findings, kept current with the permissions, and so many other daily details. Her work is pivotal to
our success. Heather, you rock.
I had a wonderful production team and I am most grateful to them. Julie Eddy, Publishing
Services Manager, supervised the schedule for book production. I am especially grateful to Jodi
Willard, Senior Project Manager, who has been in daily contact to keep the production organized
and moving. She works in so many extra ways to keep production on schedule. I am pleased with
the striking colors of the interior design of the 8th edition and the beautiful cover; both are the work
of Brian Salisbury, Book Designer. The individual page layout is the wonderful work of Leslie
Foster, Illustrator/Designer. Leslie hand-crafted every page, always planning how the page can be
made better. Because of her work, we added scores of new art and content, and we still came out
with comparable page length for the 8th edition.
I am so happy and excited to welcome Dr. Ann Eckhardt to this 8th edition. Ann has revised
numerous chapters in this edition and is gifted with new ideas. I hope her contributions continue
and grow. It has been wonderful to have a budding partner down the hall to bounce ideas and
share chapter ideas and photo shoots.
I have gifted artistic colleagues, who made this book such a vibrant teaching display. Pat Thomas,
Medical Illustrator, is so talented and contributes format ideas as well as brilliant drawings. Pat and
I have worked together from the inception of this text. While we cannot answer each other's
sentences, we have every other quality of a superb professional partnership. Chandi Kesler and
Kevin Strandberg patiently set up equipment for all our photo shoots and then captured vivid,
lively exam photos of children and adults. Julia Jarvis and Sarah Jarvis also photographed our
infant photos with patience and clarity.
I am fortunate to have dedicated research assistants. Ani Almeroth searched and retrieved
countless articles and sources. She was always prompt and accurate and anticipated my every
request. Nicole Bukowski joined as a second research assistant and has been helpful in many ways.
I am most grateful to Paul Jarvis, who read and reread endless copies of galley and page proof,
finding any errors and making helpful suggestions.
Thank you to the faculty and students who took the time to write letters of suggestions and
encouragement—your comments are gratefully received and are very helpful. I am fortunate to
have the skilled reviewers who spend time reading the chapter manuscript and making valuable
suggestions.
Most important are the members of my wonderful family, growing in number and in support.
You all are creative and full of boundless energy. Your constant encouragement has kept me going
throughout this process.
Carolyn Jarvis PhD, APRN
33

UNIT 1
Assessment of the Whole Person
OUTLINE
Chapter 1 Evidence-Based Assessment
Chapter 2 Cultural Assessment
Chapter 3 The Interview
Chapter 4 The Complete Health History
Chapter 5 Mental Status Assessment
Chapter 6 Substance Use Assessment
Chapter 7 Domestic and Family Violence Assessment
35

Evidence-Based Assessment
C.D. is a 23-year-old Caucasian woman who works as a pediatric nurse at a children's hospital. She
comes to clinic today for a scheduled physical examination to establish with a new primary care
provider (Fig. 1.1). On arrival the examiner collects a health history and performs a complete
physical examination. The preliminary list of significant findings looks like this:
1.1
• Recent graduate of a BSN program. Strong academic record
(A/B). Reports no difficulties in college.
Past medical history:
• Diagnosed with type 1 diabetes at age 12 years. Became
stuporous during a family vacation. Rushed home; admitted to
ICU with decreased level of consciousness (LOC) and heavy
labored breathing; blood sugar 1200 mg/dL. Coma × 3 days; ICU
stay for 5 days. Diabetic teaching during hospital stay; follow-up
with diabetic educator as needed.
• Now uses insulin pump. Reports HbA1c <7%.
• Finger fracture and ankle sprains during childhood (unable to
remember exact dates).
37

• Bronchitis “a lot” as a child.
• Tympanostomy tubes at age 5 due to frequent ear infections. No
issues in adulthood.
• Diabetic seizures at ages 16 and 18 caused by hypoglycemia.
Family gave glucagon injection. Did not go to emergency
department (ED).
• Denies tobacco use. Reports having 1 glass of red wine
approximately 5-6 days in the past month.
• Current medications: Insulin, simvastatin, birth control pills, fish
oil, multivitamin, melatonin (for sleep).
• Birth control since age 16 because of elevated blood sugar during
menstruation. Annual gynecologic examinations started at age 21
years. Last Pap test 6 months ago; told was “negative.”
• Family history: Mother and paternal grandfather with
hypertension; maternal grandfather transient ischemic attack, died
at age 80 from a myocardial infarction; maternal grandmother died
at age 49 of cervical and ovarian cancer; paternal grandmother
with arthritis in the hands and knees; paternal grandfather with
kidney disease at age 76; sister with migraine headaches.
• BP 108/72 mm Hg right arm, sitting. HR 76 beats/min, regular.
Resp 14/min unlabored.
• Weight 180 lbs. Height 5 ft 6 in. BMI 29 (overweight).
• Health promotion: Reports consistently wearing sunscreen when
outside and completing skin self-examination every few months.
Consistently monitors blood glucose. Walks 2 miles at least 3 days
per week and does strength training exercises 2 days per week. No
hypoglycemic episodes during exercise. Reports weekly pedicure
and foot check to monitor for skin breakdown. Biannual dental
visits. Performs breast self-examination monthly.
• Relationships: Close relationship with family (mother, father,
brother, and sister); no significant other. Feels safe in home
environment and reports having close female friends.
• Health perception: “Could probably lose some weight,” but
otherwise reports “good” health. Primarily concerned with blood
sugar, which becomes labile with life transitions.
• Expectations of provider: Establish an open and honest
relationship. Listen to her needs and facilitate her health goals.
Physical examination:
• Normocephalic. Face symmetric. Denies pain on sinus palpation.
• Vision tested annually. Has worn corrective lenses since 4th
38

grade. PERRLA.
• Scarring of bilateral tympanic membranes. Denies hearing
problems. Whispered words heard bilaterally.
• Gums pink; no apparent dental caries except for 3 noticeable
fillings. Reports no dental pain.
• Compound nevus on left inner elbow; patient reports no recent
changes in appearance. No other skin concerns.
• Breath sounds clear and equal bilaterally. Heart S1S2, neither
accentuated nor diminished. No murmur or extra heart sounds.
• Clinical breast exam done with annual gynecologic visit.
• Abdomen is rounded. Bowel sounds present. Reports BM daily.
• Extremities warm and = bilat. All pulses present, 2+ and = bilat.
No lymphadenopathy.
• Sensory modalities intact in legs and feet. No lesions.
The examiner analyzed and interpreted all the data; clustered the information, sorting out which
data to refer and which to treat; and identified the diagnoses. It is interesting to note how many
significant findings are derived from data the examiner collected. Not only physical data but also
cognitive, psychosocial, and behavioral data are significant for an analysis of C.D.'s health state. The
findings are interesting when considered from a life-cycle perspective; she is a young adult who
predictably is occupied with the developmental tasks of emancipation from parents, building an
independent lifestyle, establishing a vocation, making friends, forming an intimate bond with
another, and establishing a social group. C.D. appears to be meeting the appropriate developmental
tasks successfully.
A body of clinical evidence has validated the use of the particular assessment techniques in C.D.'s
case. For example, measuring the BP screens for hypertension, and early intervention decreases the
risk of heart attack and stroke. Monitoring blood sugar levels and HbA1c facilitates management of
her type 1 diabetes. Completing a skin assessment reveals a nevus on her elbow that needs to be
watched for any changes. Collecting health promotion data allows the examiner to personalize risk
reduction and health promotion information while reinforcing positive behaviors already in place.
The physical examination is not just a rote formality. Its parts are determined by the best clinical
evidence available and published in the professional literature.
Assessment—Point of Entry in an Ongoing Process
Assessment is the collection of data about the individual's health state. Throughout this text you
will be studying the techniques of collecting and analyzing subjective data (i.e., what the person
says about himself or herself during history taking) and objective data (i.e., what you as the health
professional observe by inspecting, percussing, palpating, and auscultating during the physical
examination). Together with the patient's record and laboratory studies, these elements form the
database.
From the database you make a clinical judgment or diagnosis about the individual's health state,
response to actual or potential health problems, and life processes. Thus the purpose of assessment
is to make a judgment or diagnosis.
An organized assessment is the starting point of diagnostic reasoning. Because all health care
diagnoses, decisions, and treatments are based on the data you gather during assessment, it is
paramount that your assessment be factual and complete.
Diagnostic Reasoning
The step from data collection to diagnosis can be a difficult one. Most novice examiners perform
well in gathering the data (given adequate practice) but then treat all the data as being equally
39

important. This leads to slow and labored decision making.
Diagnostic reasoning is the process of analyzing health data and drawing conclusions to identify
diagnoses. Novice examiners most often use a diagnostic process involving hypothesis forming and
deductive reasoning. This hypothetico-deductive process has four major components: (1) attending
to initially available cues; (2) formulating diagnostic hypotheses; (3) gathering data relative to the
tentative hypotheses; and (4) evaluating each hypothesis with the new data collected, thus arriving
at a final diagnosis. A cue is a piece of information, a sign or symptom, or a piece of laboratory or
imaging data. A hypothesis is a tentative explanation for a cue or a set of cues that can be used as a
basis for further investigation.
Once you complete data collection, develop a preliminary list of significant signs and symptoms
for all patient health needs. This is less formal in structure than your final list of diagnoses will be
and is in no particular order.
Cluster or group together the assessment data that appear to be causal or associated. For
example, with a person in acute pain, associated data are rapid heart rate, increased BP, and
anxiety. Organizing the data into meaningful clusters is slow at first; experienced examiners cluster
data more rapidly because they recall proven results of earlier patient situations and recognize the
same patterns in the new clinical situation.14 What is often referred to as nurses' intuition is likely
skilled pattern recognition by expert nurses.13
Validate the data you collect to make sure they are accurate. As you validate your information,
look for gaps in data collection. Be sure to find the missing pieces, because identifying missing
information is an essential critical-thinking skill. How you validate your data depends on
experience. If you are unsure of the BP, validate it by repeating it yourself, or ask another nurse to
validate the finding. Eliminate any extraneous variables that could influence BP results such as
recent activity or anxiety over admission. If you have less experience analyzing breath sounds or
heart murmurs, ask an expert to listen. Even with years of clinical experience, some signs always
require validation (e.g., a breast lump).
Critical Thinking and the Diagnostic Process
The standards of practice in nursing, traditionally termed the nursing process, include six phases:
assessment, diagnosis, outcome identification, planning, implementation, and evaluation.3 This is
an iterative process, allowing practitioners to move back and forth while caring for the needs of
complex patients (Fig. 1.2).
40

1.2 (Alfaro-LeFevre, 2009.)
Although the nursing process is a problem-solving approach, the way in which we apply the
process depends on our level and years of experience. The novice has no experience with a specified
patient population and uses rules to guide performance. It takes time, perhaps 2 to 3 years in
similar clinical situations, to achieve competency, in which you see actions in the context of patient
goals or plans of care. With more time and experience the proficient nurse understands a patient
situation as a whole rather than as a list of tasks. At this level you can see long-term goals for the
patient. You understand how today's interventions will help the patient in the future. Finally it
seems that expert nurses vault over the steps and arrive at a clinical judgment in one leap. The
expert has an intuitive grasp of a clinical situation and zeroes in on the accurate solution.5,6
Functioning at the level of expert in clinical judgment includes using intuition. Intuition is
characterized by immediate recognition of patterns; expert practitioners learn to attend to a pattern
of assessment data and act without consciously labeling it. Whereas the beginner operates from a
set of defined, structured rules, the expert practitioner uses intuitive links, has the ability to see
41

salient issues in a patient situation, and knows instant therapeutic responses.5,6 The expert has a
storehouse of experience concerning which interventions have been successful in the past.
For example, compare the actions of the nonexpert and the expert nurse in the following situation
of a young man with Pneumocystis jiroveci pneumonia:
He was banging the side rails, making sounds, and pointing to his endotracheal tube. He was
diaphoretic, gasping, and frantic. The nurse put her hand on his arm and tried to ascertain whether
he had a sore throat from the tube. While she was away from the bedside retrieving an analgesic,
the expert nurse strolled by, hesitated, listened, went to the man's bedside, reinflated the
endotracheal cuff, and accepted the patient's look of gratitude because he was able to breathe
again. The nonexpert nurse was distressed that she had misread the situation. The expert reviewed
the signs of a leaky cuff with the nonexpert and pointed out that banging the side rails and panic
help differentiate acute respiratory distress from pain.12
The method of moving from novice to becoming an expert practitioner is through the use of
critical thinking. We all start as novices, when we need the familiarity of clear-cut rules to guide
actions. Critical thinking is the means by which we learn to assess and modify, if indicated, before
acting. We may even be beginners more than once during our careers. As we transition to different
specialties, we must rebuild our database of experiences to become experts in new areas of
practice.1
Critical thinking is required for sound diagnostic reasoning and clinical judgment. During your
career you will need to sort through vast amounts of data to make sound judgments to manage
patient care. These data will be dynamic, unpredictable, and ever changing. There will not be any
one protocol you can memorize that will apply to every situation.
Critical thinking is recognized as an important component of nursing education at all levels.2,21
Case studies and simulations frequently are used to encourage critical thinking with students. As a
student, be prepared to think outside the box and think critically through patient-care situations.
Critical thinking goes beyond knowing the pathophysiology of a disease process and requires you
to put important assessment cues together to determine the most likely cause of a clinical problem
and develop a solution. Critical thinking is a multidimensional thinking process, not a linear
approach to problem solving.
Remember to approach problems in a nonjudgmental way and to avoid making assumptions.
Identify which information you are taking for granted or information you may overlook based on
natural assumptions. Rates of incorrect diagnoses are estimated to be as high as 10% to 15%, and
one of the primary causes of misdiagnosis is the clinician's bias.9 A 61-year-old man comes to your
clinic with complaints of shortness of breath. His history reveals a 5-pound weight gain this week
and a “fluttering in his chest.” During the physical assessment you find 2+ pitting edema in bilateral
lower extremities and an irregular apical pulse. Taken individually, ankle edema, weight gain,
shortness of breath, and palpitations may appear unrelated, but together they are signs of an
exacerbation of heart failure. Clustering of cues is extremely important in identifying a correct
diagnosis. Another patient, an overweight 20-year-old female, comes to your office for a scheduled
physical examination. Are you making assumptions about her lifestyle and eating habits? Make
sure that you double-check the accuracy of your data (subjective and objective) and avoid
assumptions that may bias your diagnosis.
Once you have clustered items that are related, you are ready to identify relevant information
and anything that does not fit. In the case of your heart failure patient, his complaints of a headache
may be viewed as unrelated to the primary diagnosis, whereas abdominal pain and difficulty
buttoning his pants are related (presence of ascites). As you gather clinical cues and complete an
assessment, also think about priority setting (Table 1.1).
TABLE 1.1
Identifying Immediate Priorities
Principles of Setting Priorities
1. Complete a health history, including allergies, medications, current medical problems, and reason for visit.
2. Determine whether any problems are related, and set priorities. Priority setting evolves over time with changes in priority depending on
the relationships between and severity of problems. For example, if the patient is having difficulty breathing because of acute rib pain,
42

managing the pain may be a higher priority than dealing with a rapid pulse.
Steps to Setting Priorities
1. Assign high priority to first-level priority problems such as airway, breathing, and circulation.
2. Next attend to second-level priority problems, which include mental status changes, acute pain, infection risk, abnormal laboratory
values, and elimination problems.
3. Address third-level priority problems such as lack of knowledge, mobility problems, and family coping.
Setting Priorities: Clinical Exemplar
You are working in the hospital and a patient is admitted to the emergency department with diabetic ketoacidosis as evidenced by a
blood glucose of >1100 mg/dL. The patient is lethargic and cannot provide a history. Based on family report, he is 12 years old and has
no significant medical, surgical, or medication history. Your first-level priorities include assuring a stable airway and adequate
breathing. Your second-level priorities include addressing mental status changes and abnormal laboratory values by intervening to
manage blood glucose levels. Once the patient has a stable blood sugar and is alert/oriented, you address third-level priorities, including
diabetic education, nutritionist consults, and referral to community support groups as appropriate.
• First-level priority problems are those that are emergent, life
threatening, and immediate, such as establishing an airway or
supporting breathing.
• Second-level priority problems are those that are next in
urgency—those requiring your prompt intervention to forestall
further deterioration (e.g., mental status change, acute pain, acute
urinary elimination problems, untreated medical problems,
abnormal laboratory values, risks of infection, or risk to safety or
security).
• Third-level priority problems are those that are important to the
patient's health but can be attended to after more urgent health
problems are addressed. Interventions to treat these problems are
long term, and the response to treatment is expected to take more
time. These problems may require a collaborative effort between
the patient and health care professionals (Fig. 1.3).
1.3
Patients often require the assistance of an interdisciplinary team of practitioners to treat complex
43

medical problems. Throughout your career, look for opportunities to work in collaborative teams
and consult other practitioners as appropriate to care for your patients. Remember, health is
complex and requires input from a variety of specialties (e.g., physical therapy, speech therapy,
occupational therapy). Once you have determined problems, you must identify expected outcomes
and work with the patient to facilitate outcome achievement. Remember, your outcomes need to be
measurable. Set small goals that can be accomplished in a given time frame. For your heart failure
patient your goal may be to eliminate supplemental oxygen needs before discharge. Include your
patient and his or her input, as appropriate, in your outcome identification. Patients are more likely
to participate actively in care and follow through with recommendations if they are part of
developing the plan of care.
The final steps to the critical-thinking process include evaluation and planning. You must
continuously evaluate whether you are on the right track and correct any missteps or
misinterpretation of data. If you are not on the right path, reassess, reanalyze, and revise. The final
step is the development of a comprehensive plan that is kept up to date. Communicate the plan to
the multidisciplinary team. Be aware that this is a legal document and that accurate recording is
important for evaluation, insurance reimbursement, and research.
Evidence-Based Assessment
Does honey help burn wounds heal more quickly? Do mobile health technologies improve patient
compliance with medication administration? Does male circumcision reduce the risk of transmitting
human immunodeficiency virus (HIV) in heterosexual men? Can magnesium sulfate reduce
cerebral palsy risk in premature infants? Is aromatherapy an effective treatment for postoperative
nausea and vomiting?
Health care is a rapidly changing field. The amount of medical and nursing information available
has skyrocketed. Current efforts of cost containment result in a hospital population composed of
people who have a higher acuity but are discharged earlier than ever before. Clinical research
studies are continuously pushing health care forward. Keeping up with these advances and
translating them into practice are very challenging. Budget cuts, staff shortages, and increasing
patient acuity mean that the clinician has little time to grab a lunch break, let alone browse the most
recent journal articles for advances in a clinical specialty.
The conviction that all patients deserve to be treated with the most current and best-practice
techniques led to the development of evidence-based practice (EBP). As early as the 1850s Florence
Nightingale was using research evidence to improve patient outcomes during the Crimean War. It
was not until the 1970s, however, that the term evidence-based medicine was coined.16 In 1972 a
British epidemiologist and early proponent of EBP, Archie Cochrane, identified a pressing need for
systematic reviews of randomized clinical trials. In a landmark case, Dr. Cochrane noted multiple
clinical trials published between 1972 and 1981 showing that the use of corticosteroids to treat
women in premature labor reduced the incidence of infant mortality. A short course of
corticosteroid stimulates fetal lung development, thus preventing respiratory distress syndrome, a
serious and common complication of premature birth. Yet these findings had not been implemented
into daily practice, and thousands of low-birth-weight premature infants were dying needlessly.
Following a systematic review of the evidence in 1989, obstetricians finally accepted the use of
corticosteroid treatment as standard practice for women in preterm labor. Corticosteroid treatment
has since been shown to reduce the risk of infant mortality by 30% to 50%.7
EBP is more than the use of best-practice techniques to treat patients. The definition of EBP is
multifaceted and reflects holistic practice. Once thought to be primarily clinical, EBP now
encompasses the integration of research evidence, clinical expertise, clinical knowledge (physical
assessment), and patient values and preferences.16 Clinical decision making depends on all four
factors: the best evidence from a critical review of research literature; the patient's own preferences;
the clinician's own experience and expertise; and finally physical examination and assessment.
Assessment skills must be practiced with hands-on experience and refined to a high level.
Although assessment skills are foundational to EBP, it is important to question tradition when no
compelling research evidence exists to support it. Some time-honored assessment techniques have
been removed from the examination repertoire because clinical evidence indicates that these
techniques are not as accurate as once believed. For example, the traditional practice of auscultating
bowel sounds was found to be a poor indicator of returning GI motility in patients having
44

abdominal surgery.17,18 Following the steps to EBP, the research team asked an evidence-based
question (Fig. 1.4). Next, best research evidence was gathered through a literature search, which
suggested that early postoperative bowel sounds probably do not represent return of normal GI
motility. The evidence was appraised to identify whether a different treatment or assessment
approach was better. Research showed the primary markers for returning GI motility after
abdominal surgery to be the return of flatus and the first postoperative bowel movement. Based on
the literature, a new practice protocol was instituted, and patient outcomes were monitored.
Detrimental outcomes did not occur; the new practice guideline was shown to be safe for patients'
recovery and a better allocation of staff time. The research led to a change of clinical practice that
was safe, effective, and efficient.
1.4 (Eckhardt, 2018.)
Evidence shows that other assessment skills are effective for patient care. For example, clinicians
should measure the ankle brachial index (ABI), as described in Chapter 21 of this text. Evidence is
clear about the value of ABI as a screening measure for peripheral artery disease.
Despite the advantages to patients who receive care based on EBP, it often takes up to 17 years for
research findings to be implemented into practice.4 This troubling gap has led researchers to
examine closely the barriers to EBP, both as individual practitioners and as organizations. As
individuals, nurses lack research skills in evaluating quality of research studies, are isolated from
other colleagues knowledgeable in research, and lack confidence to implement change. Other
significant barriers are the organizational characteristics of health care settings. Nurses lack time to
go to the library to read research; health care institutions have inadequate library research holdings;
and organizational support for EBP is lacking when nurses wish to implement changes in patient
care.15
Fostering a culture of EBP at the undergraduate and graduate levels is one way in which health
care educators attempt to make evidence-based care the gold standard of practice. Students of
medicine and nursing are taught how to filter through the wealth of scientific data and critique the
findings. They are learning to discern which interventions would best serve their individual
patients. Facilitating support for EBP at the organizational level includes time to go to the library;
teaching staff to conduct electronic searches; journal club meetings; establishing nursing research
committees; linking staff with university researchers; and ensuring that adequate research journals
and preprocessed evidence resources are available in the library.15 “We have come to a time when the
credibility of the health professions will be judged by which of its practices are based on the best and latest
evidence from sound scientific studies in combination with clinical expertise, astute assessment, and respect
for patient values and preferences.”20
Collecting Four Types of Patient Data
Every examiner needs to establish four different types of databases, depending on the clinical
situation: complete, focused or problem-centered, follow-up, and emergency.
45

Complete (Total Health) Database
This includes a complete health history and a full physical examination. It describes the current and
past health state and forms a baseline against which all future changes can be measured. It yields
the first diagnoses.
The complete database often is collected in a primary care setting such as a pediatric or family
practice clinic, independent or group private practice, college health service, women's health care
agency, visiting nurse agency, or community health agency. When you work in these settings, you
are the first health professional to see the patient and have primary responsibility for monitoring
the person's health care. Collecting the complete database is an opportunity to build and strengthen
your relationship with the patient. For the well person this database must describe the person's
health state; perception of health; strengths or assets such as health maintenance behaviors,
individual coping patterns, support systems, and current developmental tasks; and any risk factors
or lifestyle changes. For the ill person the database also includes a description of the person's health
problems, perception of illness, and response to the problems.
For well and ill people, the complete database must screen for pathology and determine the ways
people respond to that pathology or to any health problem. You must screen for pathology because
you are the first, and often the only, health professional to see the patient. This screening is
important to refer the patient to another professional, help the patient make decisions, and perform
appropriate treatments. This database also notes the human responses to health problems. This
factor is important because it provides additional information about the person that leads to
nursing diagnoses.
In acute hospital care the complete database is gathered on admission to the hospital. In the
hospital, data related specifically to pathology may be collected by the admitting physician. You
collect additional information on the patient's perception of illness, functional ability or patterns of
living, activities of daily living, health maintenance behaviors, response to health problems, coping
patterns, interaction patterns, spiritual needs, and health goals.
Focused or Problem-Centered Database
This is for a limited or short-term problem. Here you collect a “mini” database, smaller in scope and
more targeted than the complete database. It concerns mainly one problem, one cue complex, or one
body system. It is used in all settings—hospital, primary care, or long-term care. For example, 2
days after surgery a hospitalized person suddenly has a congested cough, shortness of breath, and
fatigue. The history and examination focus primarily on the respiratory and cardiovascular systems.
Or in an outpatient clinic a person presents with a rash. The history follows the direction of this
presenting concern such as whether the rash had an acute or chronic onset; was associated with a
fever, new food, pet, or medicine; and was localized or generalized. Physical examination must
include a clear description of the rash.
Follow-Up Database
The status of any identified problems should be evaluated at regular and appropriate intervals.
What change has occurred? Is the problem getting better or worse? Which coping strategies are
used? This type of database is used in all settings to follow up both short-term and chronic health
problems. For example, a patient with heart failure may follow up with his or her primary care
practitioner at regular intervals to reevaluate medications, identify changes in symptoms, and
discuss coping strategies.
Emergency Database
This is an urgent, rapid collection of crucial information and often is compiled concurrently with
lifesaving measures. Diagnosis must be swift and sure. For example, a person is brought into an ED
with suspected substance overdose. The first history questions are “What did you take?” “How
much did you take?” and “When?” The person is questioned simultaneously while his or her
airway, breathing, circulation, level of consciousness, and disability are being assessed. Clearly the
emergency database requires more rapid collection of data than the episodic database. Once the
person has been stabilized, a complete database can be compiled. An emergency database may be
compiled by questioning the patient, or if the patient is unresponsive, health care providers may
need to rely on family and friends.
46

Expanding the Concept of Health
Assessment is the collection of data about a person's health state. A clear definition of health is
important because this determines which assessment data should be collected. In general the list of
data that must be collected has lengthened as our concept of health has broadened.
Consideration of the whole person is the essence of holistic health. Holistic health views the
mind, body, and spirit as interdependent and functioning as a whole within the environment.
Health depends on all these factors working together. The basis of disease is multifaceted,
originating from both within the person and from the external environment. Thus the treatment of
disease requires the services of numerous providers. Nursing includes many aspects of the holistic
model (i.e., the interaction of the mind and body, the oneness and unity of the individual). Both the
individual human and the external environment are open systems, dynamic and continually
changing and adapting to one another. Each person is responsible for his or her own personal
health state and is an active participant in health care. Health promotion and disease prevention
form the core of nursing practice.
In a holistic model, assessment factors are expanded to include such things as lifestyle behaviors,
culture and values, family and social roles, self-care behaviors, job-related stress, developmental
tasks, and failures and frustrations of life. All are significant to health.
Health promotion and disease prevention now round out our concept of health. Guidelines to
prevention emphasize the link between health and personal behavior. The report of the U.S.
Preventive Services Task Force23 asserts that the great majority of deaths among Americans
younger than 65 years are preventable. Prevention can be achieved through counseling from
primary care providers designed to change people's unhealthy behaviors related to smoking,
alcohol and other drug use, lack of exercise, poor nutrition, injuries, and sexually transmitted
infections.10 Health promotion is a set of positive acts that we can take. In this model the focus of
the health professional is on teaching and helping the consumer choose a healthier lifestyle.
The frequency interval of assessment varies with the person's illness and wellness needs. Most ill
people seek care because of pain or some abnormal signs and symptoms they have noticed, which
prompts an assessment (i.e., gathering a complete, a focused, or an emergency database). In
addition, risk assessment and preventive services can be delivered once the presenting concerns are
addressed. Interdisciplinary collaboration is an integral part of patient care (Fig. 1.5). Providers,
nurses, dietitians, therapists and other health professionals must work together to care for
increasingly complex patients.
1.5 (Yoder-Wise, 2015.)
For the well person opinions are inconsistent about assessment intervals. The term annual checkup
is vague. What does it constitute? Is it necessary or cost-effective? How can primary-care clinicians
deliver services to people with no signs and symptoms of illness? Periodic health checkups are an
excellent opportunity to deliver preventive services and update the complete database. Although
47

periodic health checkups could induce unnecessary costs and promote services that are not
recommended, advocates justify well-person visits because of delivery of some recommended
preventive services and reduction of patient worry.11,19
The Guide to Clinical Preventive Services is a positive approach to health assessment and risk
reduction.23 The Guide is updated annually and is accessible online or in print. It presents evidence-
based recommendations on screening, counseling, and preventive topics and includes clinical
considerations for each topic. These services include screening factors to gather during the history,
age-specific items for physical examination and laboratory procedures, counseling topics, and
immunizations. This approach moves away from an annual physical ritual and toward varying
periodicity based on factors specific to the patient. Health education and counseling are highlighted
as the means to deliver health promotion and disease prevention.
For example, the guide to examination for C.D. (23-year-old female, nonpregnant, not sexually
active) would recommend the following services for preventive health care:
1. Screening history for dietary intake, physical activity, tobacco/alcohol/drug use, and sexual
practices
2. Physical examination for height and weight, BP, and screening for cervical cancer and HIV
3. Counseling for physical activity and risk prevention (e.g., secondhand smoke, seatbelt use)
4. Depression screening
5. Healthy diet counseling, including lipid disorder screening and obesity screening
6. Chemoprophylaxis to include multivitamin with folic acid (females capable of or planning
pregnancy)
C.D. is living successfully with a serious chronic condition. Because she has diabetes, including
periodic checks of hemoglobin A1c and a fasting glucose level are important. In addition, you
should ask how her pump is functioning and whether she is having any difficulties with blood
sugar control.
48

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 throughout 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. The United States is becoming a majority-minority
nation. Although non-Hispanic whites will remain the largest single group, they will no longer
constitute a numeric majority. Emerging minority is a term that has been used to classify the
populations, including African Americans, Latinos, and Asian Americans, that are rapidly
becoming a combined numeric majority.22 By 2060 the U.S. Census Bureau projects that minorities
will constitute 56% of the population. The Latino and Asian populations are projected to nearly
double by 2060, and all other racial groups are expected to increase as well. By 2060 nearly 29% of
the population will be Latino, 14% African American, 9% Asian, and just over 1% American Indians
or Alaska Natives. In 2040 the U.S. Census Bureau anticipates that there will be more people over
the age of 65 years than under the age of 18 years for the first time in history.8
The United States is becoming increasingly diverse, making cultural competence more important
and more challenging for health care providers. U.S. health care providers also travel abroad to
work in a variety of health care settings in the international community. Medical and nursing teams
volunteer to provide free medical and surgical care in developing countries (Fig. 1.6). International
interchanges are increasing among health care providers, making attention to the cultural aspects of
health and illness an even greater priority.
1.6
During your professional career you may be expected to assess short-term foreign visitors who
travel for treatments, international university faculty, students from abroad studying in U.S. high
schools and universities, family members of foreign diplomats, immigrants, refugees, members of
more than 106 different ethnic groups, and American Indians from 510 federally recognized tribes.
A serious conceptual problem exists in that nurses and physicians are expected to know,
understand, and meet the health needs of people from culturally diverse backgrounds with
minimal preparation in cultural competence.
Culture has been included in each chapter of this book. Understanding the basics of a variety of
cultures is important in health assessment. People from varying cultures may interpret symptoms
differently; therefore, asking the right questions is imperative for you to gather data that are
accurate and meaningful. It is important to provide culturally relevant health care that incorporates
cultural beliefs and practices. An increasing expectation exists among members of certain cultural
groups that health care providers will respect their “cultural health rights,” an expectation that may
conflict with the unicultural Western biomedical worldview taught in U.S. educational programs
that prepare nurses, doctors, and other health care providers.
Given the multicultural composition of the United States and the projected increase in the
49

number of individuals from diverse cultural backgrounds anticipated in the future, a concern for
the cultural beliefs and practices of people is increasingly important.
50

References
1. Alfaro-LeFevre R. Critical thinking, clinical reasoning and clinical judgment. 6th ed.
Elsevier: Philadelphia; 2017.
2. American Association of Colleges of Nursing. Essentials of baccalaureate education
for professional nursing practice. [Available at] https://www.aacnnursing.org; 2008.
3. American Nurses Association. Nursing: Scope and standards of practice. 3rd ed.
American Nurses Publishing: Washington, DC; 2015.
4. Balas EA, Boren SA. Managing clinical knowledge for health care improvements.
Bemmel J, McCray AT. Yearbook of medical informatics 2000. Schattauer: Stuttgart,
Germany; 2000.
5. Benner P, Tanner CA, Chesla CA. Expertise in nursing practice. Springer: New
York; 1996.
6. Benner P, Tanner CA, Chesla CA. Becoming an expert nurse. Am J Nurs.
1997;97(6) [16BBB–16DDD].
7. Cochrane Collaboration. [Available at] www.cochrane.org; 2018.
8. Colby SL, Ortman JM. Projections of the size and composition of the US
population: 2014 to 2060. Population Estimates and projections. [US Census Bureau]
2015.
9. Croskerry P. From mindless to mindful practice—cognitive bias and clinical
decision making. N Engl J Med. 2013;368:2445–2450.
10. Ezzati M, Riboli E. Behavioral and dietary risk factors for noncommunicable
diseases. N Engl J Med. 2013;369(10):954–964.
11. Goroll AH. Toward trusting therapeutic relationships—in favor of the annual
physical. N Engl J Med. 2015;373:1487–1489.
12. Hanneman SK. Advancing nursing practice with a unit-based clinical expert.
Image (IN). 1996;28(4):331–337.
13. Harjai PK, Tiwari R. Model of critical diagnostic reasoning: Achieving expert
clinician performance. Nurs Educ Perspect. 2009;30(5):305–311.
14. Koharchik L, Caputi L, Robb M, et al. Fostering clinical reasoning in nursing
students. Am J Nurs. 2015;115(1):58–61.
15. Lipscomb M. Exploring evidence-based practice: Debates and challenges in nursing.
Routledge: New York; 2016.
16. Mackey A, Bassendowski S. The history of evidence-based practice in nursing
education and practice. J Prof Nurs. 2017;33(1):51–55.
17. Madsen D, Sebolt T, Cullen L, et al. Listening to bowel sounds: An evidence-
based practice project. Am J Nurs. 2005;105(12):40–50.
18. Massey RL. Return of bowel sounds indicating an end of postoperative ileus: Is it
time to cease this long-standing nursing tradition? Medsurg Nurs. 2012;21(3):146–
150.
19. Mehrotra A, Prochazka A. Improving value in health care—against the annual
physical. N Engl J Med. 2015;373:1485–1487.
20. Melnyk BM, Fineout-Overholt E. Evidence-based practice in nursing & healthcare.
2nd ed. Lippincott Williams & Wilkins: Philadelphia; 2011.
21. National League for Nursing Accrediting Commission. Accreditation manual and
interpretive guidelines by program type for postsecondary and higher degree programs in
nursing. Author: New York; 2006.
22. Spector RE. Cultural diversity in health and illness. 9th ed. Pearson: Indianapolis, IN;
2016.
23. U.S. Preventive Services Task Force (USPSTF). Published recommendations.
[Available at] https://uspreventiveservicestaskforce.org; 2017.
51

Cultural Assessment
As a health professional, it is imperative that you learn to build trusting relationships with patients.
Part of forming trust is listening to each patient's individual needs and establishing an awareness of
his or her culture. You must be open to people who are different from you, have a curiosity about
people, and work to become culturally competent (Fig. 2.1). A cultural assessment is an integral
part of forming a full database of information about each patient. Serious errors can occur due to
lack of cultural competence. If you fail to ask about traditional, herbal, or folk remedies, you may
unknowingly give or prescribe a medication that has a significant interaction. For example, ginseng
raises the serum digoxin level and can lead to adverse, even fatal, consequences.18
2.1
A key to understanding cultural diversity is self-awareness and knowledge of one's own culture.
Your cultural identification might include the subculture of nursing or health care professionals.
You might identify yourself as a Midwesterner, a college student, an athlete, a member of the Polish
community, or a Buddhist. These multiple and often changing cultural and subcultural
identifications help define you and influence your beliefs about health and illness, coping
mechanisms, and wellness behaviors. Developing self-awareness will make you a better health care
provider and ensure that you are prepared to care for diverse clients. Recognizing your own
culture, values, and beliefs is an interactive and ongoing process of self-discovery.18 A cultural
assessment of each patient is important, but a cultural self-assessment is also an integral component
of becoming culturally competent. To understand another person's culture, you must first
understand your own culture.
Over the course of your professional education, you will study physical examination and health
promotion across the life span and learn to conduct numerous assessments such as a health history,
a physical examination, a mental health assessment, a domestic violence assessment, a nutritional
assessment, and a pain assessment. However, depending on the cultural and racial background of
the person, the data you gather in the assessments may vary. Therefore a cultural assessment must
be an integral component of a complete physical and health assessment.
Demographic Profile of the United States
The estimates of the U.S. population illustrate the increasing diversity in the population and
54

highlight the importance of cultural competence in health care.40 The population of the United
States exceeded 321 million people in 2015 with only 61.6% of the population identifying as white,
non-Hispanic.38 Over 13% of the U.S. population were born elsewhere, and over 21% of the U.S.
population report speaking a language other than English in the home.3,37 The national minority,
actually emerging majority, population makes up 38% of the total. Among this emerging majority,
the largest ethnic group is Hispanic, who make up 17.6% of the population and are the fastest-
growing minority group. The largest racial minority group is African American or black (13.3%),
followed by Asians (5.6%), two or more races (2.6%), American Indians and Alaska natives (1.2%),
and native Hawaiians and other Pacific Islanders (0.2%).38
There are demographic differences between the emerging majority groups when compared with
non-Hispanic whites. These demographic differences include age, poverty level, and household
composition. The number of relatives living in the household is higher for all racial and ethnic
minorities compared to non-Hispanic whites, as is the number of multigenerational families (Fig.
2.2). African Americans, American Indians, and Alaska natives are more likely to have
grandparents who are responsible for the care of grandchildren compared with other groups.37
2.2 (Courtesy Holly Birch Photography.)
Asians and non-Hispanic whites have the highest median income, whereas African Americans
have the lowest household income followed by Hispanics. All ethnic and racial minority groups
have poverty rates exceeding the national average of 14.8%. Non-Hispanic whites have the lowest
reported poverty at 10%, whereas 25.2% of African Americans and 24.7% of Hispanics live at or
below the poverty line.11 Contributing to the high rates of poverty is low educational attainment.
Approximately 33% of Hispanics and 13% of African Americans have less than a high school
education compared with 6.7% of non-Hispanic whites.33 Lower educational levels and lower
income levels are also correlated with likelihood of disability. Approximately 20% of adults report
having a disability. African Americans were the most likely to report a disability (29%), followed by
Hispanics (25.9%).6
Immigration
Immigrants are people who are not U.S. citizens at birth. Some new immigrants have minimal
understanding of health care resources and how to navigate the health care system. They may not
speak or understand English, and they may not be literate in the language of their country of origin.
Therefore it is imperative that health care providers address the needs of this growing population.
In 2014 the population of the United States included over 42.2 million foreign-born individuals,
which accounted for 13.2% of the population. The number of foreign-born individuals residing in
the United States has quadrupled since the 1960s and is expected to almost double by 2065.3 During
your career, you will care for foreign-born individuals who have unique health care needs. The
United States health care system is complex and difficult to navigate for anyone. Keep in mind, the
health care system may be even more difficult for foreign-born individuals with limited English
proficiency. Make sure that you identify interpreter needs early and ask the appropriate cultural
55

assessment questions when caring for each patient.
Determinants of Health and Health Disparities
An individual's health status is influenced by a constellation of factors known as social
determinants of health (SDOH).15 The social determinants of health include economic stability,
education, social and community context, neighborhood and built environment, and health and
health care (Fig. 2.3). The five social determinants of health are interconnected and affect a person's
health from preconception to death. However, evidenced-based research has consistently shown
that poverty has the greatest influence on health status.
2.3 (USSDHS, 2018.)
For the past two decades the goals of Healthy People have been to eliminate health disparities. A
health disparity is “a particular type of health difference that is closely linked with social, economic,
and/or environmental disadvantage. Health disparities adversely affect groups of people who have
systematically experienced greater obstacles to health based on their racial or ethnic group; religion;
socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual
orientation or gender identity; geographic location; or other characteristics historically linked to
discrimination or exclusion.”12
New health care delivery frameworks must strive for social and physical environments that
promote quality of life free from preventable illness, disability, and premature death. Public health
sectors must be encouraged to address the needs for safe and affordable housing; reliable
transportation; nutritious food that is accessible to everyone; safe, well-integrated neighborhoods
and schools; health care providers that are culturally and linguistically competent; and clean water
and air.
Health Care Disparities Among Vulnerable Populations
Health disparities affect people who experience social, economic, and/or environmental
disadvantage. These people are vulnerable populations and include ethnic and racial minorities,
people with disabilities, and the LGBT community. Health care disparities are measured by
comparing the percent of difference from one group to the best group rate for a disease. One study
found a 33-year age difference between the longest- and shortest-living groups in the United
States.13 In another example, African American children are twice as likely to be hospitalized and
four times as likely to die from asthma as non-Hispanic whites.13 Overall infant mortality in the
United States is 5.90 per 1,000 live births, but the mortality rate for African American infants is 10.93
56

per 1,000 live births.27 Lack of health insurance may contribute to health disparities. An estimated
10.6% of non-Hispanic whites do not have health insurance, whereas more than 30% of Hispanics,
nearly 19% of non-Hispanic blacks, and almost 14% of Asians lack basic insurance coverage.7
Few of the differences in health between ethnic and racial groups have a biologic basis but rather
pertain to the social determinants of health. Disparities in exposure to environmental contaminants,
violence, and substance abuse among some racial and ethnic minorities suggest the need for a major
transformation of the neighborhoods and social contexts of people's lives. Although overall quality
of health care is improving in the United States, access to care and health disparities are not
showing any improvement.14
National Cultural and Linguistic Standards
Many forms of discrimination based on race or national origin limit the opportunities for people to
gain equal access to health care services. Many health and social service programs provide
information about their services in English only. Language barriers have a negative impact on the
quality of care provided, and those patients with language barriers also have increased risk of
noncompliance to treatment regimens.
Because immigration occurs at high levels and immigrants with limited English proficiency (LEP)
have particular needs, the Office of Minority Health published the National Standards for Culturally
and Linguistically Appropriate Services in Health Care. This set of 15 standards provides a blueprint to
improve quality of care and eliminate health disparities for culturally diverse populations. Health
disparities affect the health of individuals and communities, making this a major public health
concern in the United States.39
Linguistic Competence
Under the provisions of Title VI of the Civil Rights Act of 1964, when people with LEP seek health
care in settings such as hospitals, nursing homes, clinics, daycare centers, and mental health centers,
services cannot be denied to them. English is the predominant language of the United States.
However, among people at least 5 years old living in the United States, 21% spoke a language other
than English at home.38 Of those, 62% spoke Spanish, 18% reported speaking an Indo-European
language, 16% spoke an Asian language, and 4% spoke a different language. Of people who spoke a
language other than English at home, nearly 42% reported that they did not speak English “very
well.”38
When people with LEP seek health care, they are frequently faced with receptionists, nurses, and
physicians who speak English only. Additional time and resources are necessary to adequately care
for patients with LEP. The language barrier may lead to a decreased quality of care due to limited
understanding of patient needs. To prevent serious adverse health outcomes for LEP persons, it is
imperative that health care professionals communicate effectively and utilize resources such as
interpreter services.
Chapter 3 describes in more detail how to communicate with people who do not understand
English, how to interact with interpreters, and which services are available when no interpreter is
available. It is vital that interpreters be present who not only serve to verbally translate the
conversation but who can also describe to you the cultural aspects and meanings of the person's
situation.
Culture-Related Concepts
Culture is a complex phenomenon that includes attitudes, beliefs, self-definitions, norms, roles, and
values. It is also a web of communication, and much of culture is transmitted nonverbally through
socialization or enculturation (Fig. 2.4).35 Socialization or enculturation is the process of being raised
within a culture and acquiring the norms, values, and behaviors of that group. According to the
Department of Health and Human Services Office of Minority Health, a person's culture defines
health and illness, identifies when treatment is needed and which treatments are acceptable, and
informs a person of how symptoms are expressed and which symptoms are important.39
57

2.4
Culture has four basic characteristics: (1) learned from birth through the processes of language
acquisition and socialization; (2) shared by all members of the same cultural group; (3) adapted to
specific conditions related to environmental and technical factors and to the availability of natural
resources; and (4) dynamic and ever changing.
Culture is a universal phenomenon, yet the culture that develops in any given society is unique,
encompassing all the knowledge, beliefs, customs, and skills acquired by members of that society.
However, within cultures some groups of people share different beliefs, values, and attitudes.
Differences occur because of ethnicity, religion, education, occupation, age, and gender. When such
groups function within a large culture, they are referred to as subcultural groups.
Many people think about race and ethnicity as a part of the concept of culture. Race reflects self-
identification and is typically a social construct referring to a group of people who share similar
physical characteristics. The U.S. Census Bureau lists 15 racial categories for respondents to choose
from: white, black (African American), American Indian or Alaskan native, Asian Indian, Chinese,
Filipino, Japanese, Korean, Vietnamese, native Hawaiian, Guamanian or Chamorro, Samoan, other
Pacific Islander, some other race, or more than one race. A growing number of respondents are
identifying as more than one race, especially those in younger generations. An additional question
asks respondents to identify whether they are of Hispanic origin. Hispanic origin includes the
categories of Mexican, Puerto Rican, Cuban, and another Hispanic, Latino, or Spanish origin. People
who self-identify as Hispanic can be of any racial category. For example, Dominicans typically
identify as black Hispanics, whereas people from Argentina identify as white Hispanics. Because
the terms race and origin cause confusion, the U.S. Census Bureau is considering changing the race
and origin questions so that people can select all that apply, with racial categories and Hispanic
origin combined in the same question.8
Race may be useful when determining disease prevalence, but does not typically refer to specific
genetic or biologic characteristics that distinguish one group of people from another. Throughout
the text, information on disease prevalence related to race is presented in the culture and genetics
section of each chapter. As we learn more about the human genome, we may find that genetic
variations become more important than overarching racial classifications.
Ethnicity refers to a social group that may possess shared traits, such as a common geographic
origin, migratory status, religion, language, values, traditions or symbols, and food preferences. The
ethnic group may have a loose group identity with few or no cultural traditions in common or a
coherent subculture with a shared language and body of tradition. Similarly ethnic identity is one's
self-identification with a particular ethnic group. This identity may be strongly adherent to one's
country of origin or background or weakly identified.
Acculturation is the process of adopting the culture and behavior of the majority culture. During
the late 1800s and early part of the 1900s when the United States experienced its greatest period of
immigration, the expectation was that immigrants would take on the characteristics of the dominant
culture, known as assimilation. Immigrants were discouraged from having a unique ethnic identity
in favor of the nationalist identity.
The recent wave of immigrants in the latter part of the 20th century has developed different
strategies of acculturation. Rather than solely relying on assimilation, new immigrants developed
new means of forging identities between the countries of origin and their host country, such as
58

“biculturalism” and “integration.”34 Assimilation is unidirectional, proceeding in a linear fashion
from unacculturated to acculturated. However, biculturalism and integration are bidirectional and
bidimensional, inducing reciprocal changes in both cultures and maintaining aspects of the original
culture in one's ethnic identity (Fig. 2.5).
2.5
Those who emigrate to the United States from non-Western countries may find the process of
acculturation, whether in schools or society, to be an extremely difficult and painful process. The
losses and changes that occur when adjusting to or integrating a new system of beliefs, routines,
and social roles are known as acculturative stress, which has important implications for health and
illness.9,10,36 When caring for patients, please be aware of the factors that contribute to acculturative
stress, as defined in Table 2.1.5
TABLE 2.1
Dimensions of Acculturative Stress
INSTRUMENTAL/ENVIRONMENTAL SOCIAL/INTERPERSONAL SOCIETAL
Financial
Language barriers
Lack of access to health care
Unemployment
Lack of education
Loss of social networks
Loss of social status
Family conflict
Family separation
Intergenerational conflict
Changing gender roles
Discrimination/stigma
Level of acculturation
Political/historical forces
Legal status
Modified from Caplan, S. (2007). Latinos, acculturation, and acculturative stress: a dimensional concept analysis. Policy Politics
Nurs Pract, 8(2), 93-106.
Religion and Spirituality
Other major aspects of culture are religion and spirituality. Spirituality is a broader term focused
on a connection to something larger than oneself and a belief in transcendence. On the other hand,
religion refers to an organized system of beliefs concerning the cause, nature, and purpose of the
universe, as well as the attendance of regular services.19 Religion is a shared experience of
spirituality or the values, beliefs, and practices into which people either are born or that they may
adopt to meet their personal spiritual needs through communal actions, such as religious affiliation;
attendance and participation in a religious institution, prayer, or meditation; and religious practices
(Fig. 2.6). Some people define their spirituality in terms of religion, whereas others identify
spirituality outside a formal religion.2
59

2.6 A, Mosque in Abu Dabai. B, Saint Basil's Cathedral. C, Thai spirit house. D, Buddhist shrine. (C and
D, Spector, 2009.)
The Landscape Survey detailed statistics on religion in America.29 The study found that religious
affiliation in the United States is both diverse and extremely fluid. The number of people who say
they are not affiliated with any particular faith increased from 16.1% in 2007 to 22.8% in 2015. The
number of people affiliated with Christian denominations fell from 78.4% to 70.6%, whereas those
who belong to non-Christian faiths increased from 4.7% to 5.9%. The percentage of people who
affiliate with a Christian faith has dropped, but American Christians are becoming increasingly
diverse.29 Although fewer individuals identify with a specific religion, spirituality assessment is
important for all patients regardless of religious affiliation or nonaffiliation.
In times of crisis such as serious illness and impending death, spirituality may be a source of
consolation for the person and his or her family. Religious dogma and spiritual leaders may exert
considerable influence on the person's decision making concerning acceptable medical and surgical
treatment such as vaccinations, choice of healer(s), and other aspects of the illness. Completion of a
spiritual assessment is one component of a holistic patient assessment. Understanding a patient's
spirituality can improve understanding of coping mechanisms, identify referral needs such as visits
by a chaplain, identify social support after discharge, and open discussions about medical care (e.g.,
acceptance of certain treatments such as blood transfusion). Failure to assess spiritual needs has
60

been shown to increase health care costs, especially at end of life, and unmet spiritual needs can
lead to poor outcomes.21 Religion and spirituality are associated with improved physical health,
and attending to the religious and spiritual needs of patients is an important part of holistic patient
care.19
Health-Related Beliefs and Practices
Healing and Culture
HEALTH is defined as the balance of the person, both within one's being (physical, mental, or
spiritual) and in the outside world (natural, communal, or metaphysical). It is a complex,
interrelated phenomenon. Before determining whether cultural practices are helpful, harmful, or
neutral, you must first understand the logic of the traditional belief systems coming from a person's
culture and then grasp the nature and meaning of the health practice from the person's cultural
perspective. Wide cultural variation exists in the manner in which certain symptoms and disease
conditions are perceived, diagnosed, labeled, and treated.
Beliefs About Causes of Illness
Throughout history people have tried to understand the cause of illness and disease. Theories of
causation have been formulated on the basis of ethnic identity, religious beliefs, social class,
philosophic perspectives, and level of knowledge.23 Many people who maintain traditional beliefs
would define HEALTH in terms of balance and a loss of this balance. This understanding includes
the balance of mind, body, and spirit in the overall definitions of HEALTH and ILLNESS.
Disease causation may be viewed in three major ways: from a biomedical or scientific
perspective, a naturalistic or holistic perspective, or a magicoreligious perspective.22
Biomedical
The biomedical or scientific theory of illness causation assumes that all events in life have a cause
and effect. Among the biomedical explanations for disease is the germ theory, which holds that
microorganisms such as bacteria and viruses cause specific disease conditions. Most educational
programs for physicians, nurses, and other health care providers embrace the biomedical or
scientific theories that explain the causes of both physical and psychological illnesses.20
Naturalistic
The second way in which people explain the cause of illness is from the naturalistic or holistic
perspective, found most frequently among American Indians, Asians, and others who believe that
human life is only one aspect of nature and a part of the general order of the cosmos. These people
believe that the forces of nature must be kept in natural balance or harmony.
Some Asians believe in the yin/yang theory, in which health exists when all aspects of the person
are in perfect balance.25 Rooted in the ancient Chinese philosophy of Tao, the yin/yang theory states
that all organisms and objects in the universe consist of yin and yang energy forces. The seat of the
energy forces is within the autonomic nervous system, where balance between the opposing forces
is maintained during health. Yin energy represents the female and negative forces such as
emptiness, darkness, and cold, whereas yang forces are male and positive, emitting warmth and
fullness. Foods are classified as hot and cold in this theory and are transformed into yin and yang
energy when metabolized by the body. Yin foods are cold, and yang foods are hot. Cold foods are
eaten with a hot illness, and hot foods are eaten with a cold illness. The yin/yang theory is the basis
for Eastern or Chinese medicine.
Many Hispanic, Arab, and Asian groups embrace the hot/cold theory of health and illness, an
explanatory model with origins in the ancient Greek humoral theory. The four humors of the body
—blood, phlegm, black bile, and yellow bile—regulate basic bodily functions and are described in
terms of temperature, dryness, and moisture. The treatment of disease consists of adding or
subtracting cold, heat, dryness, or wetness to restore the balance of the humors. Beverages, foods,
herbs, medicines, and diseases are classified as hot or cold according to their perceived effects on
the body, not on their physical characteristics.
According to the hot/cold theory, the person is whole, not just a particular ailment. Those who
embrace the hot/cold theory maintain that health consists of a positive state of total well-being,
61

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