INTEGRATIVE HOLISTIC
NURSING ASSESSMENT

CHAPTER 10: ASSESSING FOR VIOLENCE
Violence
• Actual, attempted, or threatened physical harm that is
deliberate and non consenting
• Includes violence against victims who cannot give full,
informed consent
• Includes fear-inducing behavior, where threats may be implicit
or directed at third parties
Aggression
- a forceful action or procedure especially when intended to
dominate or master

McCue - this theorist presented five theories related to
domestic violence for why men batter women
According to McCue why do men beat women?
Psychopathology-suffer personality disorder
Social learning
Biologic
Family system
Feminist

Walker's Cycle of Violence
This theory discuss the cyclin nature of violence. It explains that abuse
occurs in a predictable pattern
Criticism
This is the first stage of Walker's Cycle of Violence:
Tension building stage
The abuser makes unrealistic demands
Acute battering
This is the second stage of Walker's Cycle of Violence:
May be triggered by something minor but results in violence lasting up to 24 hours.
The victim is rarely able to stop the abuse

Honeymoon
This is the third stage of Walker's Cycle of Violence:
Described as a period of reconciliation
This stage begins after an incident of battery.
The abuser is loving, promises never to abuse the victim again, and
is very attentive to
the victim.
Then the cycle starts again

Family violence
The controlling, coercive behaviors seen through the
intentional acts of violence inflicted on those in familial or
intimate relationships

What are the different types of Family Violence?
• Physical abuse
• Psychological abuse
• Economic abuse
• Sexual abuse

Physical abuse
• Includes pushing, shoving, slapping, kicking, choking,
punching, and burning
• Using restraints on a victim

Psychological Abuse
Involves the use of constant insults or criticism, blaming the
victims for things that are not the victims fault, threats to hurt
children or pets.

Economic abuse
May be evidenced by preventing the victim from getting or
keeping a job, controlling money and limiting access to funds,
spending the victim's money, and controlling knowledge of
family finances

Sexual abuse
Involves forcing the victim to perform sexual act against her
or his will
Intimate partner violence

Child abuse
• Elder mistreatment
• The World Health Organization (WHO) defines child
maltreatment as “all forms of physical and emotional ill-
treatment, sexual abuse, neglect, and exploitation that results in
actual or potential harm to the child’s health, development or
dignity.” There are four main types of abuse: neglect, physical
abuse, psychological abuse and sexual abuse.

What are the categories of Family Violence?
• Intimate partner violence
-is physical, sexual, or psychological harm by a current of
former partner or spouse
• Child abuse
-According to CAPTA, a recent act of failure to act on part of a
parent or caretaker which results in death, serious physical or
emotional harm, sexual abuse or exploitation.
-Child Abuse Prevention and Treatment Act
A federal law passed in 1974 requiring physicians to report cases
of child abuse.

Elderly Mistreatment
-Neglect, Physical abuse, sexual abuse , financial abuse,
psychological abuse, exploitation, abandonment, or prejudicial
attitudes that decrease quality of life and are demeaning to
those over the age of 65 years old.

For Human trafficking victims what signs should you recognize?
• Common work and living conditions
• Poor mental health or abnormal behavior
• Poor physical health
• Lack of control
• Unable to clarify where he/she is staying/address
• Lack of knowledge of whereabouts
• Loss of sense of time
• Has numerous inconsistencies to their story

What is the physical examination to assess abuse?
Perform a general survey
Assess mental status
Evaluate vital signs
Inspect skin
Inspect the head, neck, eyes
Assess the ears, abdomen, genitalia and rectal area,
musculoskeletal system, neurologic system

What should you validate and document findings of?
• Health promotion diagnoses
• Risk diagnoses
• Actual diagnoses
• Collaborative problems
• Medical problems

Health promotion diagnosis -“a clinical judgment
concerning motivation and desire to increase well-being
and to actualize human health potential.” These responses
are expressed by the patient's readiness to enhance
specific health behaviors.

The goal of a health promotion nursing diagnosis is to
improve the overall well-being of an individual, family, or
community.
Examples of this type of nursing diagnosis include:
•Readiness for enhanced family processes
•Readiness for enhanced hope
•Sedentary lifestyle

Risk nursing diagnosis
A risk nursing diagnosis applies when risk factors require
intervention from the nurse and healthcare team prior to a real
problem developing.
Examples of this type of nursing diagnosis include:
•Risk for imbalanced fluid volume
•Risk for ineffective childbearing process
•Risk for impaired oral mucous membrane integrity
This type of diagnosis often requires clinical reasoning and
nursing judgment.

A problem-focused diagnosis (also known as actual
diagnosis) is a client problem present at the time of the
nursing assessment. These diagnoses are based on the
presence of associated signs and symptoms. Actual
nursing diagnosis should not be viewed as more
important than risk diagnoses. There are many instances
where a risk diagnosis can be the diagnosis with the
highest priority for a patient.

Problem-focused nursing diagnoses have three components: (1) nursing
diagnosis, (2) related factors, and (3) defining characteristics. Examples of
actual nursing diagnoses are:
•Ineffective Breathing Pattern related to pain as evidenced by pursed-lip
breathing, reports of pain during inhalation, use of accessory muscles to
breathe
•Anxiety related to stress as evidenced by increased tension, apprehension,
and expression of concern regarding upcoming surgery
•Acute Pain related to decreased myocardial flow as evidenced by
grimacing, expression of pain, guarding behavior.
•Impaired Skin Integrity related to pressure over bony prominence as
evidenced by pain, bleeding, redness, wound drainage.
•Delayed Surgical Recovery related to increased blood glucose level and
obesity as evidenced by poor wound healing, fatigue, and excessive time.

Collaborative problems
-are potential problems that nurses manage using both
independent and physician-prescribed interventions. These
are problems or conditions that require both medical and
nursing interventions, with the nursing aspect focused on
monitoring the client’s condition and preventing the
development of the potential complication.

Medical diagnosis is made by the physician or advanced health
care practitioner that deals more with the disease, medical
condition, or pathological state only a practitioner can treat.
Moreover, through experience and know-how, the specific and
precise clinical entity that might be the possible cause of the
illness will then be undertaken by the doctor, therefore,
providing the proper medication that would cure the illness.
Examples of medical diagnoses are Diabetes
Mellitus, Tuberculosis, Amputation, Hepatitis, and Chronic
Kidney Disease. The medical diagnosis normally does not
change. Nurses must follow the physician’s orders and carry out
prescribed treatments and therapies.

CHAPTER 11: CULTURAL
ASSESSMENT

Performing a cultural assessment
A cultural nursing assessment is a systematic way to identify the
beliefs, values, meanings, and behaviors of people while considering
their history, life experiences, and social and physical environments. In
a brief cultural assessment, you should ask about ethnic background,
religious preference, family patterns, food preferences, eating patterns,
and health practices.

Before the assessment, know the key topics to address and
know how to address them without offending the patient
and family. Determine if you’ll need an interpreter, and
identify a patient confidante who may help bridge the
cultural gap. Also, interview other providers who know the
patient to obtain relevant information. Select a strategy for
gathering data, such as a formal interview, an informal
conversation, or observation.

During the assessment, be aware of the environment. Look
around. Assess verbal and nonverbal communications.
The brief cultural assessment helps determine the need for an
in-depth cultural assessment, which can be conducted over the
course of the nurse-patient relationship, as trust builds.
Questions may include:
•What do you think caused your health problem?
•What do you think made it start when it did?
•What does your sickness do to you?
•How severe is your sickness?

•How long do you expect it to last?
•What problems has your sickness caused?
•What do you fear about your sickness?
•What kind of treatment do you think you should receive?
•What results do you hope to receive from your
treatment?
After making your nursing diagnoses, review patient and
family responses regarding cultural beliefs and Western
medical goals, so you can identify cultural factors that
may influence the effectiveness of interventions.

After establishing a culturally sensitive environment, nurses should
incorporate a cultural assessment when caring for all patients.
There are many assessment guides used for patient interviews that
are adaptable to a variety of health care settings and are designed
to facilitate understanding and communication.
The Four Cs of Culture model is an example of a quick cultural
assessment tool that asks questions about what the patient
Considers to be a problem, the Cause of the problem, how they
are Coping with the problem, and how Concerned they are about
the problem.

Four Cs of Culture
1. What do you think is wrong? What is worrying you? (In other words,
discover what the patient Considers to be the problem and what they Call
it.)
A patient with a diagnosis of pneumonia believes his body is
“unbalanced.”
2. What do you think Caused this problem? How did this happen?
The patient believes this illness is a punishment for a misdeed.
The patient avoids eating certain foods to treat the illness while also
using home remedies such as herbal tea.
3. How serious is this problem for you? How Concerned are you?
A patient views the illness as being “God’s will” and states, “It’s in God’s
hands.”

Overcoming cultural difference
As a community health nurse, you may experience cultural
difference, a sense of discomfort brought on by patient
beliefs that are difficult to negotiate. Remember, every
patient is unique, yet all have the same basic needs.

The LEARN model can help:
•Listen with sympathy and understanding to the patient’s
perception of the problem, using a nonjudgmental manner
that encourages dialogue.
•Explain your perception of the problem.
•Acknowledge and discuss the differences and similarities
between the two perceptions and build on the similarities.
•Recommend treatment from a cultural perspective.
•Negotiate an agreement regarding treatment that
incorporates cultural aspects.

Ultimately, cultivating trust, understanding, and respect will promote the
best outcomes.
You can use three approaches to facilitate the delivery of culturally
competent care: cultural preservation
cultural accommodation
cultural repatterning.
A nurse using cultural preservation supports the use of scientifically
sound cultural practices, such as acupuncture for managing pain in a
Chinese patient, and interventions from the biomedical healthcare
system, such as using lower doses of opioid analgesics.

A nurse using cultural accommodation supports and
facilitates the use of cultural practices that have not been
proven harmful—for instance, placing a key, coin, or other
metal object on the umbilicus of a Mexican newborn, which
is believed to promote healing.
A nurse using cultural repatterning works with a patient to
help him or her change cultural practices that are harmful. If,
for example, a patient comes from a culture that values the
use of herbs, a nurse needs to negotiate abstinence from
particular herbs that can cause adverse effects.

Accommodating valued traditions usually produces the desired
outcome, but the accommodation must be based on knowledge
of the culture. A nurse can gain this knowledge from
conversations, direct assessment, and other resources.
A failure to provide culturally competent care may result from a
lack of understanding, organizational pressure regarding
productivity, or peer influence. Stereotyping, prejudice, racism,
ethnocentrism, cultural blindness, cultural imposition of one’s
values on others, and cultural conflict arising from
misunderstood expectations all can diminish or destroy a
patient-nurse relationship.

Role of nurses
Community health nurses must be active in efforts to
deliver appropriate care to diverse populations. If patients
can participate in their care and have a choice in their
health-related goals, plans, and interventions, both patient
compliance and outcomes will improve. As a community
health nurse, you should constantly strive to provide the
best possible care, while continuing to learn about others
and about yourself.

Assessing spirituality and the spiritual needs of patients is fundamental
to providing effective spiritual care. Several formal spiritual assessment
tools are available to assist nurses to identify patients’ spiritual needs
and to determine whether they are experiencing spiritual distress.
However, it may be more appropriate to assess patients’ spirituality
informally, by asking open questions about their spiritual beliefs and
needs. It is important for nurses to be aware of the limits of their
competence in undertaking spiritual assessment and providing
spiritual care, and to refer patients to the healthcare chaplain or other
spiritual support personnel where necessary.

A spiritual assessment is necessary to find out if any beliefs
could impact health. There are formal spiritual assessment
tools, a few of which we will discuss later on, that help
healthcare professionals in identifying patients’ spiritual needs.
Assessment tools can also be used to see whether patients are
experiencing spiritual distress. However, informally assessing
patients’ spirituality by asking open questions about their
spiritual beliefs and needs is also an effective way to determine
patients’ spirituality. Let’s first take a look at the nature of
spirituality and the areas that need to be addressed during a
spiritual assessment.

Spirituality means different things to different people, and
it is an intensely personal issue for many. In general,
spirituality is the way in which individuals fulfill what they
believe to be the purpose of their lives. It’s a way of life
that comes from a person’s inner realm which can be from
a secular or religious point of view.

Spirituality is important to our psychological well-being because it can
provide direction and energy. Therefore, spiritual awareness can provide
these vital points:
• It helps an individual discover a sense of meaning and purpose in life
• It provides a healthy sense of belonging
• It points us in the right direction when we're seeking to define and stick
to our values
Studies support that spirituality helps prevent and heal disease. It also helps
those who are enduring distress and disability.
So, a spiritual assessment can help pinpoint areas in life that may help a
person recover.

Spiritual Beliefs
Spiritual beliefs can involve God, prayer, or meditation. Beliefs
Beliefs frequently include the relationship people have in
relation to God (or a superior being) which influences their
perspectives on life, death, and reality.
Faith
Faith usually has to do with God. People with faith in God
perceive God as essential in providing strength to deal with
daily challenges. God is called upon for help in healing
physical or mental illnesses.

Religion
Religion includes practices and rituals such as prayer or
meditation and engaging with people in the religious
community, such as fellow church members and clergy.
Spiritual and religious beliefs do overlap in many important
areas – both can have a heavy influence when it comes to
coping with illness. Also, it’s essential to look at both of
these concepts, because some individuals see themselves as
as spiritual but not necessarily religious.

Spiritual needs in healthcare can be separate and distinct from
religious ones. Spiritual beliefs may or may not be religious, but most
religious individuals are spiritual. Most people, especially when they’re
faced with illness and the questions of life and death, will have spiritual
needs and concerns that should be viewed as essential to high-quality
patient care.
To address spiritual needs, healthcare professionals must understand
how each individual fulfills their purpose in life. For some patients, it’s
in non-religious ways, and for others, it is highly religious. Therefore,
performing a spiritual assessment helps a healthcare professional learn
how spirituality can help the healing process.

In a hospital setting, religious needs could translate into
special diets, not being in a mixed-gender ward, the
availability of places to pray (non-secular or secular
chapels), the availability of chaplains in patients’ faiths, and
how people with fatal illnesses are allowed to die.

Spiritual Gifts
The spiritual gift and its expression are concepts that innate
talents, such as artistry, allow a person to better self-
expression. When spiritual gifts are used, it increases the
potential for individual success and happiness. As part of a
formula for healing, if a person is using their spiritual gifts to
bring joy to themselves or others, it can provide peace and
pleasure.

Spiritual Tools
Spiritual tools are the ways patients can help to change their
mindsets from fear to a more confident, positive approach to
the world. Some examples of spiritual tools include
meditation, practicing surrendering to a higher power daily,
taking a personal inventory, prayer, saying affirmations, and
reading devotionals.

Who Performs a Spiritual Assessment?
• Physicians
doctors are the frontline of medical care and become familiar with
their patients with repeat visits.
• Nurses
Nurses are one of the main providers of spiritual care to patients.
Hands-on nursing care in hospitals and other medical settings
permits close relationships between nurses and their patients, giving
nurses ample opportunities to provide spiritual care to patients.
• Other Healthcare Professionals
most notably psychiatrists, psychologists, and addiction t treatment
specialists, also offer opportunities for spirituality to figure into more
effective and successful treatments.

Spiritual Assessment Tool
The HOPE Assessment Tool for Spiritual Assessment can help identify
personal sources of hope and meaning, as well as spirituality and
practices.
HOPE is an acronym used in the following ways:
H: Hope, strength, comfort, and how patients deal with difficult times
O: Organized religion - learning if patients are part of a religious
community and how it helps them
P: Personal spiritual beliefs and what practices patients find most helpful
E: Effects on medical or end-of-life issues as they relate to the patient's
spiritual resources, and if there are any specific spiritual practices that
patients want to be included in their medical care

FICA Spiritual History Tool
The FICA tool is used for a clinical assessment of spirituality. The FICA spiritual
assessment can be used as a guide for spiritual history by framing questions rather
than relying on a checklist.
The FICA Spiritual History Tool gets its name from the four categories it assesses:
Faith and belief: finding out the patients' spiritual beliefs and what gives their life
meaning
Importance: discovering how spiritual beliefs are used in dealing with illness
Community: learning how patients are involved in a spiritual or religious community
Address in Care: asking how they would like their healthcare professionals to address
these spiritual issues in the healthcare process

Using the FICA spiritual assessment is an important
tool for healthcare professionals to provide the best
care to the patient. The information learned in the
assessment may direct treatment and recovery.

How Does a Spiritual Assessment Improve Healthcare?
A patient’s spiritual assessment can improve healthcare in the following ways:
 The introduction of spirituality in the doctor-patient relationship can help build
trust and understanding, which broadens the scope of the doctor-patient
relationship and increases its effectiveness.
 A spiritual assessment can help reveal spiritual or emotional challenges
affecting mental and physical health.
 Recognizing and handling spiritual issues may teach how to tap into an effective
source of coping and healing.
 Spirituality can help provide comfort during times of illness and can also
improve quality of life.

If spirituality is an important part of your life. Because findings
support that attention to the spiritual aspects of care can lead to
better outcomes, our healthcare professionals can perform a spiritual
assessment and attend to your spiritual concerns during treatment.