Culture

sexual orientation:

preferred biological sex of the partner of an individual

masturbation:

self-stimulation for sexual satisfaction

lesbian:

term for a homosexual female

biological sex:

term used to denote chromosomal sexual development—male (XY) or female (XX)

personal space:

external environment surrounding a person that is regarded as being part of that person

Race

in humans, is not a physical characteristic but a socially constructed concept that has meaning to a larger group. Anthropologists can easily show that all visible human characteristics (such as skin color; hair color and shape; eye, nose, mouth shape; body shape) vary across continua of each characteristic rather than in what would be racial groupings. For instance, the lightly waved blond hair of northern Australian aborigines, who have dark skin and broad noses, is original to these peoples and not an admixture from intermarriage with White immigrants (author's personal experience). The concept of race "originates from societal desire to separate people based on their looks and culture ... [it is] a vague, unscientific term referring to a group of genetically related individuals who share certain physical characteristics" (Bigby, 2003). However, the genetic distinctiveness does not exist. Bigby argues that race "is reflected in American society in a way that ethnicity, culture, and class are not" (p. 2) because access to resources is often based on what are called race categories that are applied in the United States to reflect minority and skin color as opposed to genetic categories. In this case, race is more a category constructed by the society with its own meaning within that society. A prime example of this is the 15 primary "race" categories used by the U.S. Government. These categories for the 2010 U.S. Government Census (Population Reference Bureau, 2009) are: White; Black/African American/Negro; American Indian/Alaska Native; Asian Indian; Chinese; Filipino; Other Asian; Japanese; Korean; Vietnamese; Native Hawaiian; Guamanian/Chamorro; Samoan; Other Pacific Islander; and Some Other Race. In addition to race categories, the U.S. 2010 Census includes a question related to origin, "Is the person of Hispanic, Latino, or Spanish origin?" Hispanic is not considered a race because this grouping is not necessarily based on genetic variation, but on geographic origin, language spoken, or self-identity. Of course, the Census categories are not truly a reflection of genetics either, as noted above. Minority often refers to a group that has less power or prestige within the society, but actually means a group with smaller population numbers. Because Caucasians are the majority in the United States and are expected to remain so for the next 30 or so years, all other groups would be minorities. But the term has a negative meaning in many contexts, indicating a group that does not hold the "majority" values or does not behave in "appropriate" ways; or groups whose members are considered to have less access to benefits and resources of the dominant culture. Another important concept is immigration. Of the nearly 324 million people comprising the U.S. population (U.S. Census Bureau, 2016), most other than Native Americans/Alaska Natives and Hawaiians are themselves immigrants or have ancestors who came to America as immigrants (although the Native American and Alaska Native groups migrated from Asia in the far distant past). However, the category of immigrant has come to refer to those who are not native born or have not become permanent resident aliens or new citizens (naturalized). These people fall into categories based on U.S. Department of Homeland Security (2015) definitions, such as the following: nonimmigrants (those in the United States for a specific purpose with permanent residence in another country); asylees or refugees (those who have a well-founded fear of persecution should they return to their country of nationality); and illegal or undocumented aliens (the official term for those commonly referred to as illegal aliens).

Zar

Experience of spirit possession. Laughing, shouting, weeping, singing, hitting head against wall. May be apathetic, withdrawn, refuse food, unable to carry out daily tasks. May develop long-term relationship with possessing spirit (not considered pathologic in the culture).

Ethically Relevant Considerations

Fletcher, Spencer, and Lombardo (2005) recommend attention to eight ethical considerations that have the greatest weight and relevance in the care of patients, which bridge between ethical principles, an ethics of caring, and the clinical situation (p. 12). 1. The Balance between Benefits and Harms in the Care of Patients. Nurses are superbly positioned to contribute to reasoning about the benefits or burdens of treatment and the related harms, since their relationships with patients enable them to see more than physiologic effects. 2. Disclosure, Informed Consent, and Shared Decision Making. There are three basic models of health care decision making. In the paternalistic model, clinicians decide what ought to be done to benefit the patient and inform the patient, and the patient's role is to comply. In the patient sovereignty model, patients or their surrogates, expressing their right to be autonomous, tell the clinician what they want, and the clinician's role is to comply. Most ethicists reject these models in their extremes and recommend a model of shared decision making, which respects and uses the preferences of the patient and the expertise and judgment of the clinician. The object of all clinical decision making is decisions that secure the health, well-being, or good dying of the patient and that honor and respect the integrity of all participants in the decision-making process. Nurses can play an important role in ensuring that patients and their surrogates receive the information and support that they need to make health care decisions that secure their interests. 3. Norms of Family Life. Most patients are not isolated individuals. Nurses who are sensitive to how a patient's injury or illness affects family members and significant others can better appreciate how this influences decisions about care, and can bring this information to the interdisciplinary team. 4. The Relationship between Clinicians and Patients. The healing encounter is central to nursing ethics. As nurses reason ethically about what should be done, it is always in the context of our relationships with and duties to patients and their families as well as with other professional caregivers. Much ethical distress for nurses results from the strong conviction that we owe individual patients more than our work environments allow us to deliver. 5. The Professional Integrity of Clinicians. While the 2015 ANA Code of Ethics for Nurses clearly states that the primary commitment of the nurse is the patient, it also states that the nurse owes the same duties to self as to others—including the responsibility to preserve integrity, to maintain competence, and to continue personal and professional growth. Nurses should think long and hard when they find themselves asked to sacrifice personal integrity to meet the needs of another. 6. Cost Effectiveness and Allocation. The increasing awareness of how difficult it is to make valued and scarce health resources available to all in need has resulted in new appreciation for the moral relevance of cost effectiveness. Nurses who are committed to patient advocacy bridge the sometimes overwhelming needs of patients and their families and the limited resources available to professional caregivers. Justice is the principle of bioethics that speaks to distributing the benefits and burdens of health care delivery fairly. Nurses are uniquely positioned within the interdisciplinary team to speak to what it means to give patients or patient cohorts "their due." 7. Issues of Cultural and/or Religious Variation. Since many conflicts about what should be done are rooted in different cultural or religious beliefs and values, nurses who are sensitive to the cultural and religious identity of patients and caregivers can help mediate these conflicts. Read more about culturally respectful care in Chapter 3. 8. Considerations of Power. Differences in power underlie many of the ethical challenges encountered in clinical practice. Injury and illness make even sophisticated consumers of health care vulnerable. Nurses and other caregivers should be vigilant to challenge any abuses of power by clinicians. Clinicians who believe that they lack power to influence care settings and delivery may also experience ethical conflict and distress.

Anatomic variation

Lower extremity venous valves vary between Caucasians and African Blacks. African Blacks have been noted to have fewer valves in the external iliac veins but many more valves lower in the leg than do Caucasians. The additional valves may account for the lower prevalence of varicose veins in African Blacks

third-person pronouns

a way of referencing a person other than the self that may or may not use gender-specific labels (e.g., he/him, she/her, they/them)

Other:

all other harmful procedures to the female genitalia for nonmedical purposes—for example, pricking, piercing, incising, scraping, and cauterizing the genital area

gender nonconformity:

behaving and appearing in ways that are considered atypical for a person's biological sex

Gender nonconformity is

behaving and appearing in ways that are considered sociologically or psychologically atypical for a person's gender.

Culturally Competent Nursing Care

The United States contains an ever-changing mix of cultural groups. More than 44 million immigrants reside in the United States or about one in seven residents is foreign born (Migration Policy Institute, 2019). The Migration Policy Institute (2019) reports that immigrants accounted for 13.7% of the total 327 million U.S. residents; adding in the U.S.-born children (of all ages) of immigrants means that approximately 90 million people, or one quarter of the overall U.S. population, is either of the first or second generation. This population is made up of numerous diverse cultural backgrounds arriving from every corner of the world into our country daily. This growing diversity has significant implications for the health care system. For years nurses have struggled with the issues of providing optimal health care that meets the needs of women, children, and their families from varied cultures and ethnic groups. In addition to displaying competence in technical skills, nurses must also become competent in caring for clients from varied ethnic and racial backgrounds. Adapting to different cultural beliefs and practices requires flexibility and acceptance of others' viewpoints. Nurses must listen to clients and learn about their beliefs about health and wellness. To provide culturally appropriate care to diverse populations, nurses need to know, understand, and respect culturally influenced health behaviors. Chapter 1 provides a more detailed discussion of culture and its impact on the health of women, children, and families. Nurses must research and understand the cultural characteristics, values, and beliefs of the various people to whom they deliver care so that false assumptions and stereotyping do not lead to insensitive care. Time orientation, personal space, family orientation (patriarchal, matriarchal, or egalitarian), and language are important cultural concepts. Although the location might be different in community-based care, these principles apply to both inpatient and outpatient settings. Utilizing cultural humility requires nurses to step outside of themselves to be open to other people's identities, in a way that acknowledges their authority over their own experiences. Nurses should possess an understanding of the perspectives, traditions, values, practices, and family systems of culturally diverse individuals, families, communities, and populations for whom they provide care, as well as knowledge of the complex variables that affect the achievement of health and well-being (U.S. Department of Health and Human Services Office of Minority Health [USDHHSOMH], 2019). Cultural competence is a dynamic process during which nurses obtain and then apply cultural information. Cultural humility goes much deeper than cultural competence because the nurse reverses roles and learns from the client about their diverse culture. Nurses must look at clients through their own eyes and the eyes of clients and family members. Nurses must develop nonjudgmental acceptance of cultural differences in clients, using diversity as a strength that empowers them to achieve mutually acceptable health care goals. Nurses must integrate their client's cultural beliefs and practices into health prescriptions to eliminate or mitigate health disparities and provide client satisfaction. Cultural competence and humility are a dynamic, lifelong learning process. Understanding the process for assessing cultural patterns and factors that influence individual and group differences is critical in preventing overgeneralization and stereotyping. A new term has been coined-cultural competemility-which blends the terms cultural competence and cultural humility. It is defined as the synergistic process between cultural humility and cultural competence in which humility permeates each of the five components of cultural competence (Campinha-Bacote, 2019). This cultural awareness allows nurses to see the entire picture and improves the quality of care and health outcomes (Box 2.4). Cultural competence or humility do not appear suddenly; they must be developed through a series of steps.

Acculturation

The circumstance when a person gives up the traits of his or her culture of origin as a result of context with another culture, to variable degrees.

Environmental control

refers to a client's ability to control the surroundings or direct factors in the environment (Giger, 2016). People who believe they have control of their health are more likely to seek care, change their behaviors, and follow treatment recommendations. Those who believe that illness is a result of nature or natural causes are less likely to seek traditional health care because they do not believe it can help them.

The ESFT model (Explanatory model of health and illness, Social and environmental factors, Fears and concerns, Therapeutic contracting) is

a cross-cultural communication tool that helps health care professionals strengthen communication and identify potential threats to treatment adherence (Box 5-3) (on page 90). Nurses can use this model to improve health care outcomes and address health disparities.

culture conflict:

situation that occurs when people become aware of cultural differences, feel threatened, and respond by ridiculing the beliefs and traditions of others to make themselves feel more secure about their own values occurs when people become aware of cultural differences, feel threatened, and respond by ridiculing the beliefs and traditions of others to make themselves feel more secure about their own values

gay:

term used to describe homosexual males

culture shock:

those feelings, usually negative, a person experiences when placed in a different culture placed in a different culture he or she perceives as strange. Culture shock may result in psychological discomfort or disturbances, because the patterns of behavior a person found acceptable and effective in his or her own culture may not be adequate or even acceptable in the new culture. The person may then feel foolish, fearful, incompetent, inadequate, or humiliated. These feelings can eventually lead to frustration, anxiety, and loss of self-esteem.

Gay (males or females) or lesbian (females) refers to

a person attracted to members of the same gender.

Subculture

A group of people with a culture that differentiates them from the larger culture of which they are a part.

Heterosexual or straight refers to

a person who experiences sexual fulfillment with a person of the opposite gender.

Ethnicity HA

A socially, culturally, and politically constructed group that holds in common a set of characteristics not shared by others with whom members of the group come into contact (Lipson & Dibble, 2007, p. xiv).

Stereotyping

An oversimplified conception, opinion, or belief about some aspect of an individual or group.

Bisexual refers to

a person who is attracted to both men and women. A bisexual relationship or encounter does not necessarily mean a person is gay.

Cultural and Ethnicity Variables

Cultural norms, also known as social norms, dictate much of our daily behavior, attitudes, and values. Therefore, it is natural that culture influences the person's response to pain. Ethnicity is a broad term that has many facets. Ethnicity generally refers to the social, religious, political, cultural, and/or psychological characteristics of a group of people that are maintained generation to generation. These characteristics provide a sense of identity and are rooted in ancestry, nationality, language, and a shared set of beliefs and values (Gagnon, Matsuura, Smith, & Stanos, 2014; Kwok & Bhuvanakrishna, 2014). Despite the understanding that the terms ethnicity and race do not capture all the complex factors that impact on the health or pain experience of people, they provide a means for: (1) beginning to describe the diversity present in the United States, (2) collecting complete data that can be shared across systems, and (3) developing a comprehensive picture of health care quality (Agency for Healthcare Research and Quality [AHRQ], 2018). Nurses should keep in mind that to provide care, there must be an appreciation that each patient's response to pain is based on a host of experiences and factors, and therefore requires an individualized care plan. For example, one patient may present with a calm, objective, matter-of-fact approach to pain, while another patient may present with loud vocalizations, an emphasis on their unique experience, physical movements, and demands for relief. Both patients are experiencing pain. It is particularly important to avoid stereotyping responses to pain because the nurse frequently encounters patients who are either in pain or anticipating that it will develop. A form of pain expression that is frowned on in one culture may be desirable in another cultural group. For example, enduring pain stoically is a sign of strength among some groups (Purnell, 2013). Be knowledgeable about cultural variations and develop an understanding of cultural influences on pain tolerance, expressions of pain, and alternative practices used to manage pain. However, intentionally involve your patient in the pain assessment by asking questions and taking care to not make assumptions or generalizations based on ethnicity or race. Health care providers increase their respect and sensitivity for diversity if they appreciate the potential effects of culture and ethnicity on the pain experience. It is important to note that the mixed ethnic heritage that is common in many patients today makes it more difficult to anticipate individual responses to pain based on their ethnicity. Asking direct questions regarding pain experiences, expectations, and management will serve you well when dealing with patients from any background. By 2044, it is projected that more than half of all Americans will belong to a minority group, with the non-Hispanic White population comprising only 44% of the population of the United States (Colby & Ortman, 2015). This more diverse population will include people from many different ethnicities, who may express themselves in many different languages. This poses potential challenges for pain assessment and management. When the patient's language differs from that of the nurse, assessment becomes even more difficult given the potential for misunderstanding the level of pain. For example, there are nuanced differences between the term pain, which usually describes the most severe discomfort, and ache, typically used to describe a dull, less severe type of discomfort. Communication is the cornerstone of a nurse's subjective assessment and associated teaching. Perceived and actual barriers to verbal and written communication should be considered and directly addressed with appropriate tools and resources. including information sheets in different languages and the use of medical interpreters. It is important to remember that the greater the language differences or barriers, the poorer a patient's pain is controlled (Purnell, 2013). Even though culture and ethnicity affect a patient's behavioral response to pain, consistent pain assessment is possible. Pain assessment tools have been translated into multiple languages and the assessment results can be similar across various cultures. A cultural accommodation such as transposing a horizontal numeric pain rating scale to a vertical presentation may simplify pain assessment for a patient who speaks only Chinese, since this is the format in which the Chinese language is read (Pasero & McCaffery, 2011). Pain rating scales are discussed later in this chapter. Recent research has confirmed that low-income and minority populations are less likely to receive the recommended treatments for pain in all health care settings. Although pain is undertreated in the general population, minority patients often experience pain for a lengthy period of time before seeking treatment for it. There tends to be a disconnect between patients' beliefs, values, health behaviors, and individual preferences and what is available to them in the conventional/dominant health care system. Geographic location (whether a remote rural or densely populated urban setting) where physical barriers limit travel or where resources are lacking can also negatively impact on pain assessment and treatment. Language problems, culturally inappropriate pain assessment tools, and prejudice and misconceptions may contribute to unsatisfactory pain outcomes. There is agreement that health care providers need to be aware of these inequities and make a concerted effort to confront these disparities (Meghani, Byun, & Gallagher, 2012; Purnell, 2013). Initiatives to address health care access and treatment disparities begin at the local and community level.

Culture

In a world moving quickly toward globalization, nurses must strive to understand diverse cultures. Culture (the view of the world and implementation of a set of traditions that are used by a specific social group in order to pass these traditions along to the next generation) plays a critical role in shaping a woman, child, or family including their health and health practices (Martin et al., 2019). Culture is a complex phenomenon involving the integration of many components such as beliefs, values, language, time, personal space, and view of the world, all of which shape a person's actions and behavior. Individuals learn these patterns of cultural behaviors from their family and community through a process called enculturation, which involves acquiring knowledge and internalizing values (Raval & Walker, 2019). Culture is learned first in the family, then in school, and then in the community and other social organizations. Culture influences every aspect of development and is reflected in childbearing and child-rearing beliefs and practices designed to promote healthy adaptation (Andrews et al., 2019). With today's changing demographic patterns, nurses must be able to incorporate cultural knowledge into their interventions so that they can care effectively for culturally diverse women, children, and families. They must be aware of the wide range of cultural traditions, values, and ethics that exist in the United States today. All nurses must establish cultural competence, the ability to apply knowledge about a client's culture so that health care interventions can be adapted to meet the needs of the client. Cultural competence refers to the process by which individuals and systems respond respectfully and effectively to people of all cultures, languages, ethnic backgrounds, disabilities, religions, sexual orientation, and other diversity factors in a manner that recognizes, and values the worth of individuals, families, and communities. Cultural humility is a process of self-reflection and discovery in order to build honest and trustworthy relationships. Being culturally competent signifies knowledge of various cultures, whereas cultural humility is an ongoing process recognizing that the person in front of you from a different culture is the expert, not the nurse (Christensen, 2019). The nurse should know about various cultural groups, ethnicity, culture-based health practices and how they may affect children, as well as the demographics of the local population. The goal is for the nurse to view culture as a point of congruence rather than a potential source of conflict. The relationship of culture to health care can become obscured by the use of broad group titles. In reality, there are many distinct cultural groups, and within a group there may be many subcultures. Geographic differences also can occur. For example, the Latin Americans living in New York may be quite different from the Latin Americans living in Florida. Nurses must be aware of these distinct cultural groups so they can provide culturally competent care. Nurses should also be aware of the traditional health care values and practices that are passed along from one generation to the next. For example, some cultures believe in consulting folk healers, and this belief may have a major influence on children's health. See Table 1.4 for some general culturally influenced beliefs and practices. It is crucial that the nurse remembers that diversity exists within cultures and this is as important as the diversity between cultures. Every child is a unique individual with his or her own beliefs, values, and history. Nurses need to avoid stereotyping, which can lead to misconceptions. Stereotyping or labeling can result from ethnocentrism, a belief that one's own ethnic group is superior to other ethnic groups. This attitude can lead to a slanted view of the world, and it may hinder the nurse's ability to provide culturally competent care.

Form of Sexual Expression

The form of sexual expression used by patients should not inflict unwanted harm on themselves or others. When sexual expression encroaches on the rights of others, it is neither healthy nor desirable. Sexual acts that violate another's rights are usually considered to be acts of aggression or hostility rather than stemming from sexual need or desire. Rape, in particular, is motivated by a need to dominate and humiliate the victim.

Language and Communication

When people from another part of the world move to the United States, they may speak their own language fluently but have difficulty speaking English. This is especially true for women or older adults in the family who do not work outside the home and for people who live in proximity to others who speak their primary language. Assimilation is likewise slower for people who stay at home, especially if they live in communities of their ethnic and cultural background. Children usually assimilate more rapidly and learn the language of the dominant culture quickly if they leave home each day to go to school and make new friends in the dominant culture. Wage earners also tend to learn a new language more quickly through the work setting. Language acquisition is thus tied to necessity and assimilation rather than to degree of difficulty. Because the United States has such a diverse population, with many languages spoken, communication problems can arise during health care activities. This problem is not unique to non-English-speaking patients; even in different regions of the country, certain dialects or word meanings can cause differences in understanding. Consider how difficult it must be to describe symptoms or give a personal health history when you do not understand the questions being asked. In addition, patients may forget English words or revert to their more familiar language when experiencing the stress of an injury, illness, or pain. Imagine for a moment finding yourself in an emergency room with crushing chest pain in a foreign country where no one speaks your language. Linguistic competence refers to the ability of caregivers and organizations to understand and effectively respond to the linguistic needs of patients and their families in a health care encounter. Nurses who work in a geographic area with a high population of residents who speak a language other than English should learn pertinent words and phrases in that language. (See the accompanying Through the Eyes of a Student account on page 86.) Many facilities also have a qualified interpreter, or one can be found in the community. To avoid misinterpretation of questions and answers, it is important to use an interpreter who understands the health care system. Sometimes a family member or friend can translate for the nurse, but such a person may be protective and not the most reliable means of transferring information; thus, guidelines discourage using family members or friends as translators. Keep in mind that talking more loudly to someone who does not understand what you are saying is not helpful. Remember that language difference is a communication problem, not a hearing problem. Make sure you are familiar with the linguistic resources available in your practice settings and pertinent policies. The U.S. Department of Health and Human Services Office of Minority Health created a health care language services implementation guide to help health care organizations implement effective language access services to meet the needs of their patients with limited English proficiency, thereby increasing their access to health care. You will find this guide, along with many other helpful resources at the website http://www.minorityhealth.hhs.gov. One of the most culturally variable forms of nonverbal communication is eye contact. The American-dominant culture emphasizes eye contact while speaking, but many other cultures regard this behavior in different ways. For example, direct eye contact may be considered impolite or aggressive by many Asians, Native Americans, Indochinese, Arabs, and Appalachians; these groups of people tend to avert their eyes while speaking. Hispanics may look downward in deference to age, biological sex, social position, economic status, or authority. Muslim-Arab women often indicate modesty by avoiding eye contact with men, and Hasidic Jewish men may avoid direct eye contact with women (Andrews & Boyle, 2016). Although the above examples are not true of all members of a group, they provide some general guidelines.

lesbain

a term that gay women, or those women who are romantically, emotionally, or sexually attracted to other women, may prefer to use

Masochism:

gaining sexual pleasure from the humiliation of being abused

bisexual

people who are romantically, emotionally, or sexually attracted to both male and female genders

gay

people who are romantically, emotionally, or sexually attracted to the same gender, such as men attracted to men

It is also vital to remember that each person may be a

member of multiple cultural, ethnic, and racial groups at one time. Therefore, different cultural values may guide a person in different situations based on what is most important to that person at the time. In addition, any person should be viewed foremost as an individual, not as a representative of a cultural group.

premenstrual syndrome (PMS):

menstrual cycle-related distress; occurs a few days before the onset of menstruation

gender

set of socially constructed norms and behaviors that are taught to women and men

Bad blood

Blood contaminated, often refers to sexually transmitted infections.

General Beliefs and Practices That May Differ Among Cultural Groups

Health and Illness Beliefs and Practices May view illness without an internal locus of control, believing illness to be God's will or the result of fate May feel uncomfortable accepting some or all aspects of Western medicine, preferring for traditional or folk healing practices or reliance on prayer Some distrust of healthcare system due to institutional bigotry and/or historic discrimination against members of their cultural group; may feel distrust also if members of their cultural group are not well represented among healthcare personnel Certain medical products or procedures may be refused due to beliefs and practices, like refusal of blood transfusion or blood products, refusal of medications derived from certain animals, and refusal of autopsy Communication and Language Preferences If a patient does not speak the language you speak, be sure to enlist the help of a medical translator. Do not use a family member to translate. Communication differences may include: • Preference in how to be addressed • Body language and posture • Tone and volume of voice • Eye contact • Level of expression and demonstration when speaking Religious and Spiritual Beliefs and Practices Individuals may vary in their beliefs about a higher power, even within single religious groups. Religious identification may or may not indicate affiliation with a place of worship or practice of prayer. Religious rules may have indications for dietary and nutritious needs, as in the examples of fasting during lent or keeping kosher and halal. Religion may influence a person or family's childbearing decisions. People of different religions may need accommodation or time during care to practice prayer. Certain medical products or procedures may be refused, like blood transfusion or blood products and medications derived from certain animals. May attribute illness to be God's will or fate May prefer traditional or folk healing practices or reliance on prayer to some Western medicine Birth and Postpartum Beliefs and Practices Concerns for modesty and privacy may vary. Some individuals may want the non-birthing parent in the room during childbirth while others prefer female family members only. Some cultures consider attending childbirth the role or responsibility of a birthing parent's mother or grandmother. Some folk beliefs and myths exist regarding eating nonnutritive substances such as clay, dirt, and sand to help relieve nausea. Superstitions exist regarding negative consequences from photographing the pregnant parent or buying the infant clothing before birth Different cultural practices exist related to the postpartum period in which some people choose not to leave their homes for a designated amount of time or the birthing parent is not expected to perform any tasks beyond breastfeeding for a certain amount of time. Individuals may have differing views on birth control and contraception that are strongly influenced by cultural and religious beliefs. Family and Gender Roles and Relationships Culture often influences the presence or degree of importance a person's family holds in their lives and whether that includes first-degree relatives or extended family. Some cultures are matriarchal while others are patriarchal. Cultural and religious views strongly influence the importance of marriage as well as childbearing decisions. Some groups emphasize the importance of and respect for older family members. Degree of parenting support may vary in correlation to how collectivist or individualist a culture is. Religion may or may not play an important role in childrearing. Some female individuals may delegate decision-making responsibilities about healthcare decisions to their male partners or the male head of the household in certain groups. Degree of stigma differs among groups regarding people who become pregnant out of wedlock. Religion and culture strongly influences which family members perform caregiving roles when a member of the family is ill.

Complementary and Alternative Medicine

In recent years, complementary and alternative medicine (CAM) has become more widely used, and socially and politically accepted in the United States. The federal government formed the National Center for Complementary and Integrative Health (NCCIH) to conduct and support research and education and to provide information on CAM to health care providers and the public. The use of CAM is not unique to a specific ethnic or cultural group: interest in CAM therapies continues to grow nationwide and will affect care of many clients. People from all walks of life and in all areas of the community use CAM. Overall, CAM use is seen more in women than men, and in people with higher educational levels. In the United States, approximately 38% of adults (about four in 10) and approximately 12% of children (about one in nine) are using some form of CAM (NCCIH, 2019). It is well known that CAM, including homeopathy, acupuncture, phytotherapy, hypnosis, and hydrotherapy, is also being used increasingly by midwives for childbirth (King et al., 2019). CAM includes diverse practices, products, and health care systems that are not currently considered to be part of conventional medicine, such as yoga, meditation, and chiropractors (NCCIH, 2019). Complementary medicine is used together with conventional medicine, such as using aromatherapy to reduce discomfort after surgery or to reduce pain during a procedure or during early labor. Alternative medicine is used in place of conventional medicine, such as eating a special natural diet to control nausea and vomiting or to treat cancer instead of undergoing surgery, chemotherapy, or radiation that has been recommended by a conventional doctor. Integrative medicine combines mainstream medical therapies and CAM therapies for which there is some scientific evidence of safety and effectiveness. These include acupuncture, reflexology, therapeutic touch, meditation, yoga, herbal therapies, nutritional supplements, homeopathy, naturopathic medicine, and many more used for the promotion of health and well-being (Micozzi, 2019). The philosophy of integrative medicine focuses on treating the whole person, not just the disease. The goal is to treat the mind, body, and spirit all at the same time. History has taught us that in science application of the results is never determined by a single study, but by the weight of the evidence. It is right that medicine rests upon a foundation that begins with good clinical observations, case reports, and careful interpretations. Replication across scientists, which is the true hallmark of valid science, establishes whether those clinical observations are important and perhaps applicable. While some of the therapies used are nonconventional, a guiding principle within integrative medicine is to use therapies that have some high-quality evidence to support them (Simon, 2019). Integrative medicine combines conventional Western medicine with complementary treatments—all in the effort to treat the whole person. The nurse should avoid judgment and encourage the family to research all approaches that are evidence based that support healthy outcomes. Table 2.2 describes selected CAM therapies and treatments. The theoretic underpinnings of complementary and alternative health practices propose that health and illness are complex interactions of the mind, body, and spirit. It is then surmised that many aspects of clients' health experiences are not subject to traditional scientific methods. This field does not lend itself readily to scientific study or to investigation and therefore is not easily embraced by many hard-core scientists (Micozzi, 2019). Much of what is considered to be alternative medicine comes from the Eastern world, folk medicine, and religious and spiritual practices. There is no unifying basic theory for the numerous treatments or modalities, except (as noted previously) that health and illness are considered to be complex interactions among the body, mind, and spirit. Because of heightened interest in complementary treatments and their widening use, anecdotal efficacy, and growing supporting research evidence, nurses need to be sensitive to and knowledgeable enough to answer many of the questions clients ask and to guide them in a safe, objective way (Lindquist et al., 2018). Nurses have a unique opportunity to provide services that facilitate wholeness. They need to understand all aspects of CAM, including costs, client knowledge, and drug interactions, if they are to promote holistic strategies for clients and families. With all of the enthusiasm in favor of CAM therapies, nurses must not forget their obligation to embrace the principles of EBP and critical evaluation before being misled into therapies that have no scientific basis to justify their use. The growing use of complementary and alternative therapies during pregnancy and childbirth could be interpreted as a response by women regarding a need for autonomy and active participation in their health care during this time. Studies show that massage, acupuncture, vitamins, and herbs are the most frequently applied methods during pregnancy. In a recent study, only half of the pregnant women revealed their use of CAM to their health care provider during their prenatal visits ( Jordan et al., 2019). Many clients who use complementary or alternative therapies do not reveal this fact to their health care provider. Therefore, one of the nurse's most important roles during the assessment phase of the nursing process is to encourage clients to communicate their use of these therapies to eliminate the possibility of harmful interactions and contraindications with current medical therapies. When assessing clients, ask specific questions about any nonprescription medications they may be taking, including vitamins, minerals, or herbs. Clients should also be asked about any therapies they are taking that have not been ordered by their primary health care provider. When caring for clients and their families who practice CAM, nurses need to: be culturally sensitive to nontraditional treatments. acknowledge and respect different beliefs, attitudes, and lifestyles. keep an open mind, remembering that standard medical treatments do not work for all clients. accept CAM and integrate it if it brings comfort without harm. provide accurate information, not unsubstantiated opinions. advise clients how they can best monitor their condition using CAM. discourage practices only if they are harmful to the client's health. instruct the client to weigh the risks and benefits of CAM use. avoid confrontation when asking clients about CAM. be reflective, nonjudgmental, and open-minded about CAM. The use of complementary therapies is widespread, especially by women desiring to alleviate the nausea and vomiting of early pregnancy. Ginger powder or tea, Sea-Bands (acupressure), hypnosis, and vitamin B6 are typically used to treat morning sickness (Cunningham et al., 2018). Although these may not cause any ill effects during the pregnancy, most substances ingested cross the placenta and have the potential to reach the fetus, so nurses should stress to all pregnant women that it is better to be cautious when using CAM. Women at risk for osteoporosis are seeking alternatives to menopausal hormone therapy since the Women's Health Initiative (WHI) study raised doubts about the benefit of estrogen. Some of the alternative therapies for osteoporosis include soy isoflavones, progesterone cream, magnet therapy, tai chi, mindfulness meditation, yoga, and hip protectors (NCCIH, 2018). In addition, menopausal women may seek CAM therapies for hot flashes. Once again, despite many claims, most of these therapies have not undergone scientific testing and thus could place the woman at risk. If clients are considering the use of or using CAM therapies, suggest they check with their health care provider before taking any "natural" substance. Offer clients the following instructions: Do not take for granted that because a substance is a natural herb or plant product, it is beneficial or harmless. Seek medical care when ill. Find out the education and credentials of the person suggesting this therapy. Always inform the provider if you are taking herbs or other therapies. Seek out the findings of scientific studies that validate that therapy's effectiveness. Be suspicious of any treatment that says it does not have any side effects. Be sure that any product package contains a list of all ingredients and amounts of each. Be aware of any treatment that says it can "cure" a difficult to treat disease/condition. Be aware that frequent or continual use of large doses of a CAM preparation is not advisable, and harm may result if therapies are mixed (e.g., vitamin E, garlic, and aspirin all have anticoagulant properties). Research CAM through resources such as books, websites, and articles (Micozzi, 2019). All nurses, especially nurses working in the community, must educate themselves about the pros and cons of CAM and be prepared to discuss and help their clients make sense of it all. Expanding our consciousness by understanding and respecting diverse cultures and CAM will enable nurses to provide the best treatment for clients and their families receiving community-based care. Clients in any setting expect nurses to initiate communication on CAM. Providing clients in the community with evidence-based counseling about CAM is essential for improving client safety and better outcomes.

Kava kava (Piper methysticum)

Used to decrease anxiety Can increase the effect of anesthesia

Cultural, Ethnic, and Religious Considerations

Individuals' culture, ethnicity, or personal beliefs determine to a large extent which foods are eaten and how they are prepared and served. Cultural and religious practices can determine whether certain foods are prohibited (Chart 4-6) and whether certain foods and spices are eaten on holidays or at specific family gatherings. Because of the value of food pattern choices to many individuals, the nurse must be sensitive to these choices when obtaining a dietary history. Equally important, the nurse must not stereotype individuals and assume that because they are from a certain culture or religious group, they adhere to specific dietary customs. Specific eating patterns, such as vegan or vegetarian, should be explored so that appropriate dietary recommendations can be offered (U.S. Department of Agriculture [USDA] & HHS, 2019). Deficiencies in certain diets may cause disorders such as anemia (see Chapter 29 for further discussion). The cultural context of food varies widely but usually includes one or more of the following: relief of hunger; promotion of health and healing; prevention of disease or illness; expression of caring for another; promotion of interpersonal closeness among individual people, families, groups, communities, or nations; and promotion of kinship and family alliances. Food is also associated with strengthening of social ties; observance of life events (e.g., birthdays, marriages, funerals); expression of gratitude or appreciation; recognition of achievement or accomplishment; validation of social, cultural, or religious ceremonial functions; facilitation of business negotiations; and expression of affluence, wealth, or social status. Culture influences which foods are served and when they are served, the number and frequency of meals, who eats with whom, and who receives the choicest portions. Culture also may influence how foods are prepared and served, how they are eaten (with chopsticks, hands, or fork, knife, and spoon), and where people shop (e.g., ethnic grocery stores, specialty food markets). Culture also determines the impact of excess weight and obesity on self-esteem and social standing. In some cultures, physical bulk is viewed as a sign of affluence and health (e.g., a chubby baby is a healthy baby). Religious practices may include fasting (e.g., Catholics, Buddhists, Jews, Muslims) and abstaining from selected foods at particular times (e.g., Catholics abstain from meat on Ash Wednesday and on Fridays during Lent). Practices may also include the ritualistic use of food and beverages (e.g., Passover dinner, consumption of bread and wine during religious ceremonies; see Chart 4-6). Most groups feast, often in the company of family and friends, on selected holidays. For example, many Christians eat large dinners on Christmas and Easter and consume other traditional high-calorie, high-fat foods, such as seasonal cookies, pastries, and candies. These culturally based dietary practices are especially significant in the care of patients with diabetes, hypertension, gastrointestinal disorders, obesity, and other conditions in which diet plays a key role in the treatment and health maintenance regimen.

Ephedra (Ma-Huang)

Appetite suppressant May interact with medications to cause increased BP and HR

Assessment for lgbtq

Nurses should strive to create a welcoming, inclusive, and therapeutic relationship with every patient. To better achieve this type of relationship with people who are LGBTQ, nurses should use inclusive terms and language. This will increase the likelihood of eliciting accurate information from anyone whose experience is different from cultural norms (Eliason & Chinn, 2018). Using inclusive language conveys to the person who is LGBTQ that the interviewer is open to hearing about their sexuality, gender identity, and relationships. If a nurse does not yet know a patient's sexual orientation and gender identity, they should always use neutral language to ensure the patient is comfortable during the assessment (see the Resources section at the end of the chapter for educational materials that promote developing welcoming and inclusive patient-provider relationships). In the United States, people tend to communicate using a binary gender system (female or male) and based on the assumption that people are heterosexual. This type of communication practice can be harmful to people who are LGBTQ, especially in the health care setting. Nurses should strive to use language terms that avoid assumptions about a patient's gender identity and sexual orientation. For example, nurses should avoid using singular third-person pronouns (a way of referencing a person other than the self that may use gender-specific labels) and salutations that use gender-specific labels (e.g., sir/miss/madam, Mr./Mrs./Ms.) until confirming the patient's preferences. They should also avoid using terms that assume sexual orientation of the patient and their family (e.g., wife/husband, boyfriend/girlfriend, mother/father). Table 54-1 provides specific examples of neutral questions and statements. Nurses should routinely assess each patient's sexual orientation and gender identity (SO/GI), including preferred pronouns. In fact, national and federal recommendations for routine collection of SO/GI in health care settings have spanned nearly 20 years (Maragh-Bass, Torain, Adler, et al., 2017). Assessing for SO/GI in the health care setting facilitates the provision of enhanced, holistic, person-centered care. For example, people who are LGBTQ may have unique health risks that need attention or may have a diverse family structure. People who are LGBTQ typically want to disclose their SO/GI to health care professionals. However, most health care professionals do not ask about SO/GI and instead make assumptions about a patient's gender identity and presume every patient is heterosexual. These assumptions put the burden on the patient to disclose ("come out" about their SO/GI), putting them in a vulnerable position (Eliason & Chinn, 2018). Thus, nurses should be skilled at properly assessing for SO/GI and preferred pronouns (Chart 54-1). Assessing for family structure and other important relationships should be routine for every patient. People who are LGBTQ may have diverse or nontraditional family structures and may include people who are not biologically related. Nurses should assess for family and family of choice. Family of choice is a commonly used term among people who are LGBTQ. Some people who are LGBTQ have been rejected by their family of origin and thus create their own family network of people who support and care for them (Eliason & Chinn, 2018). Moreover, some people who are LGBTQ fear discrimination and exclusion of not only themselves but also their family. This is especially true of people who live in states that sanction narrow definitions of legal relationships Nurses should use neutral terms and be sensitive when interviewing all people about their family structure. Since some people who are LGBTQ have nontraditional family structures and families of choice, it is best to start the interview with an open-ended question, such as "Tell me about your family and social support system." As the nurse asks follow-up questions, neutral terms should be used when inquiring about partners/significant others and parents/guardians (examples are listed in Table 54-1). Also, the nurse should not assume a person who is LGBTQ does not have children. Many people who are LGBTQ have children through adoption, surrogacy, and previous relationships. If the patient has children, the nurse should avoid making assumptions about the family structure. Finally, the nurse should mirror the language and terms used by the patient and their family. For example, if a male-identifying patient refers to his significant other as "husband," the nurse should not choose to use a different term, such as "partner." In terms of health assessment, people who are LGBTQ typically do not require specific assessments or diagnostic tests. They should receive nursing and medical person-centered care like any other patient. Depending on the health care setting, the nurse may want to focus parts of their assessment on those health risks mentioned earlier in the chapter. Time could be spent asking the person who is LGBTQ about anxiety, depression, suicidality, and discrimination and victimization. Since gay and bisexual men and transgender women have higher rates of HIV, sexual activity, safe sex practices, and HIV status should be assessed. People who identify as transgender should be asked about hormone treatment and surgical procedures only if it is relevant to the care being provided.

Sharp

Pain is sticking in nature and that is intense.

Female-to-Male Gender Reassignment Surgeries

There are also numerous different gender reassignment surgeries for transgender men (see Table 54-4). Male-sexed faces tend to have larger facial skeletons, be squarer with sharper angles and stronger jaws. Although facial masculinization procedures are far less common than facial feminization, surgeries are available to modify the forehead, angle of the mandible, chin, and cheekbones. Although the vocal cords can be surgically modified to reduce tension resulting in a more masculine voice, most people who are transgender male achieve their desired voice through testosterone treatment and behavioral therapies (Irwig, 2017; Schneider & Courey, 2016). Testosterone treatment has little effect on reducing breast size, thus transgender men who desire a flat chest require a subcutaneous mastectomy (Fig. 54-4). From an anatomical standpoint, subcutaneous mastectomy in transgender males is nearly identical to mastectomies for breast disease. The main difference is the removal of breast tissue and excess skin and reduction and repositioning of the nipple and areola to create an aesthetically pleasing male chest (Colebunders, D'Arpa, Weijers, et al., 2016). The complication rate of subcutaneous mastectomy is very low and carries similar risk to mastectomies for breast disease Some transgender men choose to have phalloplasty, which is the construction of a penis. The goals of phalloplasty include (Colebunders, D'Arpa, et al., 2016): •having an aesthetic appearing penis, achieving tactile and erogenous sensation, having the ability to urinate while standing, and having the ability to have an erection and engage in penetrative intercourse. Phalloplasty is a complicated surgery that involves numerous subprocedures. Although the selection of subprocedures will depend on the patient's goals, they typically include phallic shaft creation, penile urethroplasty, urethral lengthening, perineoplasty (reconstructing the perineum), scrotoplasty, vaginectomy, hysterectomy and oophorectomy, glansplasty (constructing the head of penis), testicular implants, and erectile device implant (Heston, Esmonde, Dugi, et al., 2019). To help retain erogenous sensation and the ability to achieve orgasm, surgeons try to maintain clitoral nerves. Patients can also elect to have clitoral transposition where the clitoris is placed in a superficial location just below the surface of the neophallus. Constructing the penis requires a flap of skin to be excised from either the radial forearm or anterolateral thigh. The forearm skin flap is considered as the standard in penis construction (Fig. 54-5), but some patients may choose the thigh to avoid having a wide circumferential scar on the forearm. Due to the size of the skin flap excised from the forearm or thigh, postoperative monitoring and care is imperative to prevent infection and complications. After surgery, the patient typically remains in bed for 1 week with a suprapubic urinary diversion and transurethral catheter. The patient may be prescribed an LMWH agent, such as enoxaparin, during this time frame. However, pelvic or groin hematomas sometimes develop postphalloplasty, which must then be managed by either drains or surgical drainage, and thus the individual risks versus the benefits of prescribing an LMWH agent are carefully considered (Crane, 2016). After the 1-week mark, the transurethral catheter is removed, and the suprapubic catheter is clamped so the patient can begin voiding. The patient will typically remain hospitalized for 2 to 3 weeks after a phalloplasty for close monitoring. To increase the aesthetic aspect of the phalloplasty, the patient may choose to tattoo the glans (head) of the penis after it has healed. Tattooing the glans allows for more natural coloring (Colebunders, D'Arpa, et al., 2016). There are numerous challenges to achieving the last two goals of phalloplasty; namely, to urinate while standing and to achieve an erection. There have been many reported complications in patients who had urethral lengthening through construction of a neourethra, especially postoperative urethra fistulas and strictures/stenoses. Further, the long-term effects of urethral lengthening on bladder function is unknown. Lifelong follow-up with a urologist is usually required. Achieving rigidity (erection) after a phalloplasty remains a real challenge. There are numerous surgical approaches to creating rigidity, each with unique limitations and complications. One of the more common approaches is implanting an erectile device. Although infections can be a problem with penile implants, the latest erectile devices show promise in being durable and allowing the person to achieve an erection and sexual pleasure (Colebunders, D'Arpa, et al., 2016) (for further discussion of penile implants, see Chapter 53, Table 53-2). An alternative technique to phalloplasty is metoidioplasty, which uses the clitoris to construct a microphallus. In metoidioplasty, the clitoris is detached from the pubic bone, allowing it to extend out further. This approach usually requires at least 12 months of testosterone treatment, which results in a hormonally hypertrophied clitoris. Metoidioplasty is the only procedure that enables creation of male genitalia with completely preserved protective and erogenous sensitivity. This means that the sexual sensation of the clitoris is preserved and intact, which differs from a phalloplasty that often requires reconstruction or transposition of the clitoris. The scrotum is usually created from labia majora flaps allowing for testicular implants. Compared to phalloplasty, metoidioplasty has a shorter hospital stay and minimal donor site complications. However, metoidioplasty does not allow the person to void while standing nor engage in penetrative sex

Physical environment

Information is elicited about the type of housing (e.g., apartment, duplex, single family) in which the person lives, its location, the level of safety and comfort within the home and neighborhood, and the presence of environmental hazards (e.g., social isolation, potential fire risks, inadequate sanitation). If the patient is homeless, details about available resources are important to ascertain.

Cultural Influences during the Postpartum Period

African American • Mother may share care of the infant with extended family members. • Experiences of older women within the family influence infant care. • Mothers may protect their newborns from strangers for several weeks. • Mothers may not bathe their newborns for the first week. Oils are applied to skin and hair to prevent dryness and cradle cap. • Silver dollars may be taped over the infant's umbilicus in an attempt to flatten the slightly protruding umbilical stump. • Sleeping with parents is a common practice. Amish • Women consider childbearing their primary role in society. • Generally oppose birth control. • Pregnancy and childbirth are considered a private matter; may conceal it from public knowledge. • Women typically do not respond favorably when hurried to complete a self-care task. Nurses need to take cues from women indicating their readiness to complete morning self-care activities. Appalachian • Infant colic is treated by passing the newborn through a leather horse's collar or administering weak catnip tea. • An asafetida bag (a gum resin with a strong odor) is tied around the infant's neck to ward off disease. • Women may avoid eye contact with nurses and health care providers. • Women typically avoid asking questions even if they do not understand directions. • The grandmother may rear the infant for the mother. Filipino American • Grandparents often assist in the care of their grandchildren. • Breastfeeding is encouraged, and some mothers breastfeed their children for up to 2 years. • Women may feel uncomfortable discussing birth control and sexual matters. • Strong religious beliefs predominate, and bedside prayer is common. • Families are close-knit and numerous visitors can be expected at the hospital after childbirth. Japanese American • Cleanliness and protection from cold are essential components of newborn care. Nurses should bathe the infant daily. • Newborns are routinely not taken outside the home because it is believed that they should not be exposed to outside or cold air. Infants are kept in a quiet, clean, warm place for the first month of life. • Breastfeeding is the primary method of feeding. • Many women stay in their parents' home for 1 to 2 months after birth. • Bathing the infant can be the center of family activity at home. Mexican American • The newborn's grandmother lives with the mother for several weeks after birth to help with housekeeping and child care. • Many women will breastfeed for more than 1 year. The infant is carried in a rebozo (shawl) that allows easy access for breastfeeding. • Women may avoid eye contact and may not feel comfortable being touched by a stranger. Nurses need to respect this preference. • Some women may bring religious icons to the hospital and may want to display them in their rooms. Muslim • Modesty is a primary concern; nurses need to protect the client's modesty. • Muslims often will not eat pork; check all food items before serving. • Muslims may prefer a same-sex health care provider; male-female touching is prohibited except in an emergency situation. • A Muslim woman often stays in the house for 40 days after birth, being cared for by female members. • Most women will breastfeed, but some holidays and religious events call for periods of fasting, which may increase the risk of dehydration or malnutrition. • Women are exempt from obligatory five-times-daily prayers as long as lochia is present. • Extended family is likely to be present throughout much of the woman's hospital stay. They may need an empty room to perform prayers without having to leave the hospital. Native American • Women may be secretive about pregnancies and choose to not reveal them early. • Touching is not a typical female behavior, and eye contact is brief. • Resent being hurried and need time for sitting and talking. • Most mothers breastfeed and practice birth control.

Chiropractic therapy

Aimed at removing irritants to the nervous system to restore proper function—spinal manipulation done for musculoskeletal complaints

prohibited foods and drinks for mormonism

Alcohol Beverages containing caffeine stimulants (coffee, tea, colas, and selected carbonated soft drinks)

prohibited foods and drinks for seventh-day adventism

Alcohol Beverages containing caffeine stimulants (coffee, tea, colas, and selected carbonated soft drinks) Pork Certain seafood, including shellfish Fermented beverages Note: Optional vegetarianism is encouraged.

Communication

All communication is culturally based. Verbal communication can have many variations based on both language differences and usual tone of voice. For instance, a harsh tone of voice may be normal in some cultures and thought to be rude in others. Nonverbal communication has the most often misinterpreted variations. These variations include patterns of space, eye contact, body language and hand gestures, silence, and touch. Time is also interpreted to be a form of communication when two people from different cultures perceive time differently.

Medications Prescribed to Facilitate Gender Transition

Androgen-Reducing Medications (Antiandrogen) Spironolactone (off-label use) Mechanism of action: diuretic that also directly inhibits testosterone secretion and androgen binding to the androgen receptor Electrolyte imbalances, especially hyperkalemia Decreased blood pressure This medication is a diuretic and patients must be advised of frequent urination and need to increase water intake. Caution in patients with adrenal insufficiency, diabetes, hyperkalemia, and chronic kidney disease. Cyproterone acetate Mechanism of action: antiandrogenic and progestogenic/antigonadotropic properties, resulting in blocked binding of the active metabolite of testosterone and decreased production of testicular testosterone Thromboembolism Hyperlipidemia Hepatotoxicity Glucose intolerance Mood changes Assess for signs and symptoms of thromboembolism. Monitor mood changes (anxiety, depression, insomnia), especially during the first 4-6 wks. Monitor liver function tests prior to and during therapy for symptoms of hepatotoxicity. Dutasteride Finasteride Mechanism of action: inhibits the enzyme 5-alpha reductase, which is responsible for converting testosterone to its potent metabolite Prostatic hyperplasia Assess for urinary hesitancy, feeling of incomplete bladder emptying, interruption of urinary stream, and dysuria. Estrogen Ethinyl estradiol Mechanism of action: semisynthetic estrogen that binds to estrogen receptors, increasing estrogen levels and decreasing testosterone levels Thromboembolism Edema Hypertension Pancreatitis Assess for signs and symptoms of thromboembolism. Assess blood pressure before and during therapy. Monitor hepatic function during therapy. Testosterone undecanoate Mechanism of action: synthetic testosterone that binds to androgen receptors throughout body Glucose intolerance Hypertension Assess blood pressure before and during therapy. Monitor for hypoglycemia, especially in people taking diabetes medications.

Components of Learning Needs Assessment

Assess • Learner characteristics: Find out more about the child and family's life and how the child's illness has affected it. Learn more about the child and family's social, cultural, and spiritual values. • Learner needs and readiness: Including what they want and need to know and what they know already; readiness and willingness to learn; motivation to learn and emotional concerns; capacity to learn such as physical or cognitive abilities including ability to read and developmental level. • Learning style: Determine how the child and family learn best, as well as preferred learning methods and modalities, such as audio, video, written or modeling. • Learning barriers: Identify cultural or language barriers, cognitive or physical disabilities, presence of pain, and lack of support network.

Bulimia nervosa

Associated with intense fear of obesity. Binge eating and self-induced vomiting, laxative, or diuretic use.

Anorexia nervosa

Associated with intense fear of obesity. Severely restricted food and calorie intake.

NURSING PROCESS The Patient Undergoing Gender Reassignment Surgery

Assessment Preoperatively, the nurse should first gather details about the patient's gender identity, preferred name, preferred pronouns, and surgery. A person who is undergoing gender reassignment surgery will likely feel vulnerable and emotional. Gender reassignment surgery is a monumental moment for a person who is transgender. The nurse needs to ensure the patient and their family feel welcomed and safe. Using gender-neutral language (see Table 54-1) and properly assessing for gender identity and pronouns (see Chart 54-1) is imperative to creating a welcoming environment. Preoperatively, the nurse ensures the patient has received education and counseling about their gender reassignment surgery, the possible risks and benefits, including complications, postsurgical outcomes, and need for possible long-term follow-up appointments. The nurse needs to assess the last time the patient took their hormone treatment (e.g., estrogen or testosterone) because certain procedures require the patient to stop hormones 2 to 3 weeks in advance of surgery. The nurse should ensure the patient completed their bowel preparation, especially in genital reassignment surgery. For patients undergoing phalloplasty, the nurse needs to assess smoking status because most surgeons require the patient to be free of tobacco products or inhaling nicotine and marijuana. This includes electronic nicotine delivery systems (ENDS) including e-cigarettes, e-pens, e-pipes, e-hookah, and e-cigars (Colebunders, D'Arpa, et al., 2016). Laboratory results, including complete blood count (CBC), electrolytes, blood urea nitrogen (BUN), and creatinine, should be assessed; however, the nurse should be aware that people who receive hormones may have alterations in their laboratory values (Tollinche, Walters, Radix, et al., 2018). For patients who are transitioning, regardless of whether the transition is female to male or male to female, the upper limit for creatinine, hemoglobin and hematocrit, and alkaline phosphatase should be based on male values. For patients who are transitioning from female to male, the lower limit of hemoglobin and hematocrit should be based on male values. For patients who are transitioning from male to female, the lower limit of hemoglobin and hematocrit should be based on female values (WPATH, 2012). Postoperatively, the nurse assesses the patient to ensure the goals for recovery are met and that the patient exhibits absence of complications secondary to the surgical procedure(s). Gender reassignment surgeries often require very specific assessments to ensure proper healing and prevent complications. It is imperative that the nurse follow the surgeon's prescribed postoperative care guidelines and educate the patient to prevent both complications and revisional surgeries (Colebunders, Verhaeghe, et al., 2016). Diagnosis NURSING DIAGNOSES Based on the assessment data, major nursing diagnoses may include the following: •Risk for compromised dignity associated with stigmatization •Anxiety associated with impending surgery •Acute pain associated with surgical procedure •Risk for infection associated with surgical procedure •Hope associated with gender reassignment surgery COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS Potential complications may include the following: •Hemorrhage •Venous thromboembolism (VTE) •Tissue necrosis Planning and Goals The major goals for the patient include enhanced sense of dignity and respect, reduction of anxiety about the surgery and postoperative care, relief of pain, absence of infection, enhancement of hope related to life after surgery, effective peripheral tissue perfusion, and absence of postoperative complications. Nursing Interventions ENSURING HUMAN DIGNITY The nurse needs to promote a welcoming and safe environment for the patient undergoing gender reassignment surgery. In addition, the nurse needs to promote the use of gender-neutral language, preferred third-person pronouns, and utmost respect for the patient and their family (Johnson, Wakefield, & Garthe, 2020). The patient should be able to safely disclose their gender identity and sexual orientation. In addition, nurses and other health care providers should avoid having discussions about the patient that can be overheard by neighboring patients and staff who are not involved in care. While this principle should be applied to all patients, it is of the utmost importance to the care of people who are transgender because of concerns over discriminatory health care treatment (Tollinche et al., 2018). People who are transgender should be roomed in accordance with their gender identity. Careful communication between the nurse and individuals responsible for room assignments (e.g., charge nurse) is necessary. If a private room is available, it should be offered as an option because it will provide increased privacy and comfort to the patient. However, the patient should not be forced into a private room because it may make the patient feel isolated (Tollinche et al., 2018). REDUCING ANXIETY The nurse provides the patient preparing for gender reassignment surgery anticipatory guidance as to what to expect during the surgery and postoperatively. The patient's preferred family should be included when possible to help reduce anxiety. Additionally, some surgery centers promote the use of relaxation techniques, such as aromatherapy, nature sounds, and relaxation exercises; the nurse should use these if available (Ertug, Olusoylu, Bal, et al., 2017). People who are transgender are often connected to larger networks, but the nurse can promote local and online support groups. Often, online support groups can become the main support resource after gender reassignment surgery (Cipolletta, Votadoro, & Faccio, 2017) (see Resources section). Additionally, to help ease the patient's anxiety about postoperative care, the nurse can assist in coordinating services. People who are transgender have higher rates of anxiety and depression than cisgender people. These issues may be exacerbated during a prolonged hospital stay. Thus, the nurse should advocate for the involvement of mental health, social work, and spiritual care as needed to address all of the patient's needs (Tollinche et al., 2018). RELIEVING PAIN Evidence shows that patients experiencing postoperative pain should be offered multimodal analgesia, which is the pharmacologic method of combining various groups of medications for pain relief (Manworren, Gordon, & Montgomery, 2018) (see Chapter 9 for further discussion). After surgery, patients are usually prescribed opioid (morphine, hydromorphone) and nonopioid (acetaminophen or NSAIDs) agents. The nurse can administer these agents as prescribed to relieve pain and discomfort. Inadequately controlled postoperative pain can impede functional recovery and reduce quality of life (Manworren et al., 2018), thus nurses need to be vigilant about controlling the patient's pain. Patients undergoing genital reassignment surgery typically need to stay in bed for numerous days; thus, the nurse should help the patient reposition themselves to promote comfort. PREVENTING AND MONITORING FOR INFECTION Unless the patient undergoing gender reassignment surgery has risk factors (e.g., older adult, weak immune system, smoker, poor nutrition, overweight), they are not at greater risk for developing a postsurgical infection. The nurse should follow usual procedures to prevent and monitor for infection. Preventing infection after surgery requires proper and frequent hand hygiene, maintenance of the surgical site, and administration of prescribed prophylactic antibiotics. Early signs of infection should be reported to the surgeon immediately, including increased skin redness, pain, or swelling, cloudy or discolored discharge from the surgical site, and fever. PROMOTING HOPE People who are transgender often experience greater levels of depression and decreased quality of life as compared with cisgender people. However, people who undergo gender reassignment surgery often experience improved quality of life (Cai, Hughto, Reisner, et al., 2019; Passos, Teixeira, & Almeida-Santos, 2019). The nurse should promote open communication about the patient's feelings, hopes, and goals after their gender reassignment surgery and show a positive regard and sense of hope for the patient. Additionally, the nurse may want to explore unresolved emotions or anxieties. MONITORING AND MANAGING POTENTIAL COMPLICATIONS After surgery, the nurse assesses the patient for complications from the procedure, such as hemorrhage, VTE, and tissue necrosis. Hemorrhage. Postoperative hemorrhage is a possible complication after gender reassignment surgery, especially following vaginectomy, which is one of the procedures during a phalloplasty (Colebunders, D'Arpa, et al., 2016). Signs and symptoms of possible hemorrhage include increased pain, frank red blood from the surgical site or rectum, increase in bloody output from any drain that might be in place (e.g., for mastectomy), and typical clinical manifestations (e.g., tachycardia, hypotension, lightheadedness, syncope). Venous Thromboembolism. People who undergo gender reassignment surgery, especially those undergoing genital surgery and those who are transgender women, are at risk of VTE, including both pulmonary embolism (PE) and deep vein thrombosis (DVT) (Shatzel, Connelly, & DeLoughery, 2017). People who undergo genital reassignment surgery often need to stay in bed for up to 7 days, putting them especially at risk. Additionally, the estrogen hormone treatment among transgender women increases the risk. The patient is typically prescribed mechanical compression (e.g., intermittent pneumatic compression devices) and prophylactic anticoagulation with subcutaneous LMWH agents (e.g., enoxaparin) during hospitalization. Even with these prophylactic measures, some patients still develop DVT and PE, and thus the nurse should monitor for clinical signs (Colebunders, Verhaeghe, et al., 2016; Shatzel et al., 2017) (see Chapter 26 for further discussion on VTE). Tissue Necrosis. Tissue necrosis from vascular compromise is a complication with certain gender reassignment surgeries, including subcutaneous mastectomy and phalloplasty. After the subcutaneous mastectomy, vascular compromise may occur around the reconstructed nipple and areola (Colebunders, Verhaeghe, et al., 2016). After the phalloplasty, vascular compromise may occur in the reconstructed shaft, penis glans, or scrotum (Colebunders, D'Arpa, et al., 2016). Signs of tissue necrosis from vascular compromise include skin/tissue discoloration (blue or black), feeling cool to the touch, increased pain or decreased sensation, and poor wound healing. Tissue necrosis is a medical emergency that needs to be addressed immediately. PROMOTING HOME, COMMUNITY-BASED, AND TRANSITIONAL CARE Educating Patients About Self-Care. People who undergo gender reassignment surgery are typically discharged to home from the hospital within seven days after surgery. General postoperative discharge education includes promptly notifying the surgeon for a temperature greater than 38°C (100.4°F) or for the presence of unusual or bloody drainage from the wound(s). The patient is encouraged to advance the diet as tolerated at home to promote wound healing and to abstain from all tobacco products at least until the surgical wound(s) has healed. Additional education provided is dependent upon the nature of the surgery. For instance, the patient who has had a vaginoplasty or phalloplasty will receive very specific education (Charts 54-4 and 54-5). If the patient has had a mastectomy and has a drain in place, then the patient needs to be educated on managing the drain at home (see Chapter 52, Chart 52-7: Home Care Checklist: Patient with a Drainage Device Following Breast Surgery). The patient is discharged with specific instructions about follow-up appointments, including visits with their surgical, medical, and psychosocial providers to address their complex needs. Nurses should advocate that these follow-up appointments be made prior to hospital discharge. Additionally, the discharge process should assist the patient in coordinating any type of necessary equipment pickup, transportation to follow-up appointments, and filling medication prescriptions, as needed. Continuing and Transitional Care. Gender reassignment surgery is very complex, involves numerous different procedures, and can be different from surgeon to surgeon. For these reasons, it is impossible to describe every postsurgical self-care activity. The nurse needs to carefully review the discharge instructions provided by the surgical team. Genital reassignment surgery often has very specific self-care requirements of the patient. The nurse's role is to ensure the patient fully understands the self-care instructions and knows how to monitor for complications. The patient will usually continue to see their surgeon for follow-up appointments for many months. Some procedures, such as a phalloplasty, may require follow-up appointments for up to a year after surgery. The patient will typically need lifelong hormonal treatment and should continue to follow-up with their endocrinology health care provider. Additionally, many people who undergo gender reassignment surgery continue to visit a mental health care provider for counseling. Evaluation Expected patient outcomes may include the following: 1.Enhanced human dignity a.Verbalizes feelings of satisfaction related to the level of respect given to them 2.Minimal anxiety a.Has facial expressions, gestures, and activity levels that reflect decreased distress b.Demonstrates ability to reassure self 3.Relief of pain a.Reports relief of pain b.Engages in early mobilization activities as prescribed

Relating to Patients From Different Cultures

Assess your personal beliefs surrounding people from different cultures. Review your personal beliefs and past experiences. Set aside any values, biases, ideas, and attitudes that are judgmental and may negatively affect care. Assess communication variables from a cultural perspective. Determine the ethnic identity of the patient, including generation in the United States. Use the patient as a source of information when possible. Assess cultural factors that may affect your relationship with the patient and respond appropriately. Plan care based on the communicated needs and cultural background. Learn as much as possible about the patient's cultural customs and beliefs. Encourage the patient to reveal cultural interpretation of health, illness, and health care. Be sensitive to the uniqueness of the patient. Identify sources of discrepancy between the patient's and your own concepts of health and illness. Communicate at the patient's personal level of functioning. Evaluate effectiveness of nursing actions and modify nursing care plan when necessary. Modify communication approaches to meet cultural needs. Be attentive to signs of fear, anxiety, and confusion in the patient. Respond in a reassuring manner in keeping with the patient's cultural orientation. Be aware that in some cultural groups, discussion concerning the patient with others may be offensive and may impede the nursing process. Understand that respect for the patient and communicated needs is central to the therapeutic relationship. Communicate respect by using a kind and attentive approach. Learn how listening is communicated in the patient's culture. Use appropriate active listening techniques. Adopt an attitude of flexibility, respect, and interest to help bridge barriers imposed by culture. Communicate in a nonthreatening manner. Conduct the interview in an unhurried manner. Follow acceptable social and cultural amenities. Ask general questions during the information-gathering stage. Be patient with a respondent who gives information that may seem unrelated to the patient's health problem. Develop a trusting relationship by listening carefully, allowing time, and giving the patient your full attention. Use validating techniques in communication. Be alert for feedback that the patient does not understand. Do not assume meaning is interpreted without distortion. Be considerate of reluctance to talk when the subject involves sexual matters. Be aware that in some cultures, sexual matters are not discussed freely with members of the opposite sex. Adopt special approaches when the patient speaks a different language. Use a caring tone of voice and facial expression to help alleviate the patient's fears. Speak slowly and distinctly, but not loudly. Use gestures, pictures, and play acting to help the patient understand. Repeat the message in different ways if necessary. Be alert to words the patient seems to understand and use them frequently. Keep messages simple and repeat them frequently. Avoid using medical terms and abbreviations that the patient may not understand. Use an appropriate language dictionary. Use interpreters to improve communication. Ask the interpreter to translate the message, not just the individual words. Obtain feedback to confirm understanding. Use an interpreter who is culturally sensitive.

Therapeutic touch

Balancing of energy by centering, invoking an intention to heal, and moving the hands from the head to the feet several inches from the skin

Cultural Norms of the Health Care System

Beliefs Standardized definitions of health and illness Omnipotence of technology Critical importance of safety and quality measures Practices Maintenance of health and prevention of illness Annual physical examinations and diagnostic procedures Habits Documentation Frequent use of jargon Use of a systematic approach and problem-solving methodology Likes Promptness Neatness and organization Compliance Dislikes Tardiness Disorderliness and disorganization Customs Professional deference and adherence to the pecking order found in autocratic and bureaucratic systems Use of certain procedures attending birth and death

Whites

Breast cancer Heart disease Hypertension Diabetes mellitus Obesity

Mal de ojo (evil eye)

Children, infants at greatest risk; women more at risk than men. Cause often thought to be stranger's touch or attention. Sudden onset of fitful sleep, crying without apparent cause, diarrhea, vomiting, and fever.

FACTORS INFLUENCING PAIN children

Children, like adults, experience neurologic events that result in the perception of pain. However, research has found that environmental and psychological factors may exert a greater influence on the child's perception of pain (McGrath, 2005). Certain factors such as age, gender, cognitive level, temperament, previous pain experiences, and family and cultural backgrounds cannot be changed. However, situational factors involving behavioral, cognitive, and emotional aspects can be modified.

Asian traditions

Chinese medical practitioners, herbalists Prevent or rebalance yin/yang, hot/cold foods and conditions, wear amulets, acupuncture, cupping, moxibustion

Spell

Communicates with dead relatives or spirits, often with distinct personality changes (not considered pathologic in culture of origin).

Important Factors in Cultural Assessment

Communication Physical distance or space Social organization Time orientation Environmental control Biologic variations

Prevention of Unwanted Pregnancy

Contraception is a process or technique for preventing pregnancy by means of a medication, device, or method that blocks or alters one or more of the processes of reproduction in such a way that sexual intercourse can occur without impregnation. The prevention of unwanted pregnancy must be a conscious decision. Anyone who is unprepared for pregnancy should refrain from intercourse or obtain a contraceptive method from a health care provider or from the pharmacy; it is too late to think about contraception during sexual intercourse. To practice responsible sex, the contraceptive method must be used consistently and according to instructions.

Contexts for Assessment

Culture includes contexts beyond the basic beliefs and behaviors that vary. Culture also includes family structure and function, spirituality and religion, and community, which serve as context for growth and development, health and illness, and health care delivery. Together these form the major contexts for seeing a client as an individual or from a specific group. Each individual or group is inseparable from the background contexts. The nurse must perceive the client within these contexts and be able to assess aspects of these contexts when performing a health assessment

Health Care Beliefs

Cultural beliefs that affect health care involve beliefs about communication (which affect the culturally competent interview process, described previously), beliefs about the appropriate categories of persons to whom an individual goes to seek health care (Table 11-1), and beliefs about health and illness. First, a culturally competent nurse must understand the variation in beliefs about causes of illness. Then it becomes fairly easy to understand what treatments will be expected and from whom the treatments or care will be sought.

Beliefs about Causes of Illness

Culture has the most influence on a person's health beliefs and practices. It has been shown to influence one's concept of disease and illness. Two prevalent types of beliefs about what causes illness in non-Western cultures are natural and unnatural or personal. Unnatural or personal beliefs attribute the cause of illness to the active, purposeful intervention of an outside agent, spirit, or supernatural force or deity. The natural view is rooted in a belief that natural conditions or forces, such as cold, heat, wind, or dampness, are responsible for the illness (Giger, 2016). A sick person with these beliefs would not see the relationship between his or her behavior or health practices and the illness. Thus, he or she would try to counteract the negative forces or spirits using traditional cultural remedies rather than taking medication or changing his or her health practices. Stigma may still exist in situations in which the cultural or personal beliefs about mental illness or seeking help are cause for guilt or shame. A person may experience shame for having mental health issues or for needing to seek outside help (Yakeley, 2018). Suicidal ideation is oftenan issue that is stigmatized and associated with weakness or failure of personal or religious beliefs (Keller, McNeill, Honea, & Paulson Miller, 2019).

Taijinkyofusho (Japan)

Dread of offending or hurting others by behavior or physical condition such as body odor. Social phobia.

Empacho

Especially in young children, soft foods believed to adhere to stomach wall. Abdominal fullness, stomach ache, diarrhea with pain, vomiting. Confirmed by rolling egg over stomach and egg appears to stick to an area.

Family Support

Family as a source of social support can be a key factor in the recovery of clients with psychiatric illnesses. Although family members are not always a positive resource in mental health, they are most often an important part of recovery. Health care professionals cannot totally replace family members. The nurse must encourage family members to continue to support the client even while he or she is in the hospital and should identify family strengths, such as love and caring, as a resource for the client.

Sample Questions and Statements Using Gender-Neutral Language

Good morning, sir. Good morning. How may I help you, ma'am? How may I help you? She is scheduled for an x-ray. They are scheduled for an x-ray. Do you have a husband? Are you in a relationship? What are the names of your mom and dad? What are the names of your parents or guardians?

Assessing a Woman with a Disability

Health History Address questions directly to the woman herself rather than to people accompanying her. Ask about: •Self-care limitations resulting from her disability (ability to feed and dress self, the use of assistive devices, transportation requirements, other assistance needed) •Sensory limitations (lack of sensation, low vision, deaf or hard of hearing) •Accessibility issues (ability to get to health care provider, transfer to examination table, accessibility of office/clinic of health care provider, previous experiences with health care providers, health screening practices, her understanding of physical examination) •Cognitive or developmental changes that affect understanding •Limitations secondary to disability that affect general health issues and reproductive health and health care •Sexual function and concerns (those of all women and those that may be affected by the presence of a disabling condition) •Menstrual history and menstrual hygiene practices •Physical, sexual, or psychological abuse (including abuse by care providers; abuse by neglect, withholding or withdrawing assistive devices or personal or health care) (see Chart 50-3) •Presence of secondary disability (i.e., those resulting from the patient's primary disability: pressure injuries, spasticity, osteoporosis, etc.) •Health concerns related to aging with a disability Physical Assessment Provide instructions directly to the woman herself rather than to people accompanying her; provide written or audiotaped instructions. Ask the woman what assistance she needs for the physical examination and provide assistance if needed: •Undressing and dressing •Providing a urine specimen •Standing on scale to be weighed (provide alternative means of obtaining weight if she is unable to stand on scale) •Moving on and off the examination table •Assuming, changing, and maintaining positions Consider the fatigue experienced by the woman during a lengthy examination and allow rest. Provide assistive devices and other aids/methods needed to allow adequate communication with the patient (interpreters, signers, large-print written materials). Complete examination that would be indicated for any other woman; having a disability is never justification for omitting parts of the physical examination, including the pelvic examination. Adapted from Konig-Bachman, M., Zenzmaier, C., & Schildberger, B. (2019). Health professionals' views on maternity care for women with physical disabilities: A qualitative study. BMC Health Services Research, 19(1), 551.

CULTURAL INFLUENCES ON GROWTH AND DEVELOPMENT toddler

Homelessness or poverty may directly influence the toddler's ability to grow adequately, as resources for the purchase and preparation of appropriate food may be lacking. Appropriate toys (safe ones) may also not be available in those situations. Food customs continue to have an impact on the child's diet and ability to ingest appropriate nutrients. Individual family value systems have an impact on the toddler's development as well. Some parents desire to keep their child a "baby" for a longer period, thus delaying weaning or continuing to feed the child baby food or puréed food for a longer period. Other families may highly value independence and encourage the toddler to walk everywhere on his or her own rather than carry the child. Culture may also affect emotional development. Some families start at a very young age to discourage crying in boys, encouraging them to "act like a big boy" or "be a man." Ridicule for crying at this age may hurt the toddler's self-concept. Educating families about normal growth and development while continuing to value and support cultural practices is important (Martorell, 2019).

Western European traditions

Homeopathic physicians, physicians, and other health professionals Maintain physical and emotional well-being with proper science-based modern nutrition, exercise, cleanliness, belief in and faith in God

Cultural Patterns and Differences

Knowledge of cultural patterns provides a starting point for the nurse to begin to relate to people with ethnic backgrounds different from his or her own (Andrews & Boyle, 2015). Being aware of differences can help the nurse know what to ask or how to assess preferences and health practices. Nevertheless, variations among people from any culture are wide; not everyone fits the general pattern. Individual assessment of each person and family is necessary to provide culturally competent care that meets the client's needs. The nurse must learn about greetings, acceptable communication patterns and tone of voice, and beliefs regarding mental illness, healing, spirituality, and medical treatment in order to provide the best care possible.

African traditions

Magico herbalist, Hoodoo (also known as conjurers), or other traditional healers known as "Old Lady," "granny," or lay midwife Magical and herbal mix of herbs, roots, and rituals, talismans or amulets

Select Gender Reassignment Surgeries

Male to Female Female to Male Facial feminization •Angle of mandible •Cheeks •Chin •Forehead •Nose •Upper lip Facial masculinization •Angle of mandible •Cheekbones •Chin •Forehead Hair transplantation Subcutaneous mastectomy Chondrolaryngoplasty (tracheal shave) Hysterectomy and salpingo-oophorectomy Voice feminization Phalloplasty Breast augmentation Orchiectomy Vaginoplasty

Female Contraceptives

Most of the contraceptive products that will soon be available for women are refinements of products already available. New barrier methods for women will include enhanced cervical caps and vaginal sponges with microbicides to protect against STIs. New contraceptive pills, patches, and rings for women will use varied combination of hormones. Injectable progestin products may one day protect against pregnancy for up to 90 days. Oral and injectable vaccines may one day immunize women against pregnancy. These vaccines might produce antibodies to attack egg or sperm, or the immune system might create antibodies to a crucial type of protein molecule found on the head of sperm. Contraceptive implants designed to remain effective for 2 or 3 years, as well as biodegradable implants with efficacy of up to 18 months, are in development. Computerized fertility monitors that predict ovulation will offer couples who use FAMs of contraception a much more sophisticated and accurate charting method. Methods for permanent sterilization will expand to include chemical scarring techniques and insertion of fallopian tube chemical plugs and cryosurgery. Temporary sterilization may be effected by the use of silicone plugs.

Low blood

Not enough or weak blood caused by diet.

Latah (Malaysia)

Occurs after traumatic episode or surprise. Exaggerated startle response (usually in women). Screaming, cursing, dancing, hysterical laughter, may imitate people, hyper suggestibility.

Wacinko (Oglala Sioux)

Often reaction to disappointment or interpersonal problems. Anger, withdrawal, mutism, immobility, often leads to attempted suicide.

Gerontologic Considerations

Older women function at various levels across the health spectrum; some function at a high level in their jobs or families, whereas others may be very ill. Nurses need to be prepared to care for older women who may be bright, energetic, and ambitious or who are coping with multiple family crises, including their own health issues, as well as for those who are experiencing a life-altering or life-threatening health problem. Older women are at risk for several conditions, including diabetes, dyslipidemia, hypertension, and thyroid disease, all of which have symptoms that may be dismissed as typical aging. Nurses can help prevent morbidity and mortality from these conditions by encouraging women to obtain regular health screenings (Eliopoulos, 2018). Knowledge about heart disease prevention, pharmacology, diet, signs of dementia or cognitive decline, fall prevention, osteoporosis prevention, gynecologic and breast cancers, and sexuality are important for providing high-level nursing care. Health disparities, cultural competency, and end-of-life issues also need to be considered.

Diffuse

Pain covers a large area. Usually, the patient is unable to point to a specific area without moving the hand over a large surface, such as the entire abdomen.

Continuous Intermittent Brief or transient

Pain does not stop. Pain stops and starts again. Pain passes quickly.

Dull

Pain is not as intense or acute as sharp pain, possibly more annoying than painful. It is usually more diffuse than sharp pain

Pain

Pain is now the fifth vital sign in U.S. health care. Assessing pain is necessary for each client (see Chapter 9). However, the experience of pain may vary by cultural conditioning. Some believe that pain is punishment for wrongdoing; others believe it is atonement for wrongdoing. The response to pain is based on cultural values. When the caregiver and the client come from different cultures, interpreting the actual level of pain being felt is difficult. It is necessary to explain the therapeutic reasons for treating pain so that a person from a stoic culture may become less reluctant to express or describe pain.

analysis of nutritional status

Physical measurements (BMI, waist circumference) and biochemical and dietary data are used in combination to determine a patient's nutritional status. Often, these data provide more information about the patient's nutritional status than the clinical examination, which may not detect subclinical deficiencies unless they become so advanced that overt signs develop. A low intake of nutrients over a long period may lead to low biochemical levels and, without nutritional intervention, may result in characteristic and observable signs and symptoms. A plan of action for nutritional intervention is based on the results of the dietary assessment and the patient's clinical examination. To be effective, the plan should include a healthy diet, maintenance (or control) of weight, and compensation for increased nutritional needs.

prohibited foods and drinks for islam

Pork Alcoholic products and beverages (including extracts, such as vanilla and lemon) Animal shortenings Gelatin made from pork, marshmallow, and other confections made with gelatin Note: Halal is lawful food that may be consumed according to tenets of the Koran, whereas Haram is food that is unlawful to consume.

Spiritual healing

Praying, chanting, presence, laying on of hands, rituals, and meditation to assist in healing

Acupressure

Restoration of balance by pressing an appropriate point so self-healing capacities can take over

Ataque de nervios

Results from stressful event and build up of anger over time. Shouting, crying, trembling, verbal or physical aggression, sense of heat in chest rising to head.

Mal puesto or brujeria

See rootwork entry under Africa and African Origin in Americas in this table.

Shen kui (China) Dhat (India)

Similar conditions that result from the belief that semen (or "vital essence") is being lost. Anxiety, panic, sexual complaints, fatigue, weakness, loss of appetite, guilt, sexual dysfunction with no physical findings.

Susto

Spanish word for "fright," caused by natural means (cultural stressors) or supernatural means (sorcery or witnessing supernatural phenomenon). Nervousness, anorexia, insomnia, listlessness, fatigue, muscle tics, diarrhea.

Feng shui (pronounced fung shway)

The Chinese art of placement. Objects are positioned in the environment to induce harmony with chi

family and culture

The child's cultural and family background will influence how he or she will express and manage pain. Some cultures transmit the standard of accepting pain stoically; others allow outward expression. The parents have a strong influence on the child's ability to cope. For example, if a parent reacts to the child's pain in a positive manner and offers comfort measures, the child may have an easier time coping. If the parent shows anger or disapproval, the pain experience may be intensified for the child.

Cultural diversity

The co-existence of a difference in behavior, traditions, and customs—in short, a diversity of cultures, often resulting from cross-border population flows; perhaps better referred to as "cultural pluralism"

Unisex Reversible Contraceptives

The concept of unisex reversible contraception is being explored. This method involves a group of drugs called gonadotropin-releasing hormone (GnRH) agonists and can be used to prevent the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the pituitary gland. The release of FSH and LH triggers ovulation and spermatogenesis. Blocking the release of these hormones will temporarily suppress fertility for women or men. In addition, various contraceptive injections, implants, and vaccines for men are being researched.

Herbal medicine

The therapeutic use of plants for healing and treating diseases and conditions

Culture HA

The totality of socially transmitted behavioral patterns, arts, beliefs, values, customs, lifeways, and all other products of human work and thought characteristic of a population or people that guide their worldview and decision making

Severity Severe or excruciating Moderate Slight or mild

These terms depend on the patient's interpretation of pain. Behavioral and physiologic signs help assess the severity of pain. On a scale of 0-10, slight pain could be described as being between 1 and 3; moderate pain, between 4 and 7; and severe pain, between 8 and 10.

Vitamin E

Thought to slow the aging process Can increase bleeding and may cause BP problems

Body Language and Hand Gestures

Two major hand gestures of note are those for indicating height and those for indicating "OK." Latins and others indicate height of an animal the way Americans indicate height of people—by putting the hand level at the indicated height. Latins indicate height for humans by bending the fingers up and putting the back of the hand at the height level. The Latin gesture is not noticed much by Americans, but the American gesture is an insult to Latins. The way Americans sign OK by making a circle with the thumb and forefinger is a definite and serious insult in many cultures around the world. Thus if any hand gesture is used, be sure to clarify if there seems to be a strange or unexpected reaction on the other person's part.

Hi-Waitck (Mohave)

Unwanted separation from a loved one. Insomnia, depression, loss of appetite, and sometimes suicide.

Alternative forms of sexual expression include the following:

Voyeurism, Sadism, Masochism, Sadomasochism, Pedophilia

Postpartum Cultural Beliefs

With increasing multiculturalism in the United States, understanding various cultures' views of the postnatal period as it relates to their recovery and well-being after childbirth is important for all nurses. Postpartum nurses need to understand these diverse cultural beliefs and provide creative strategies for encouraging hygiene (sponge baths, perineal care), exercise, and balanced nutrition while remaining respectful of the cultural significance of different practices. The best approach is to ask each woman to describe what cultural practices are important to her and plan accordingly.

Cisgender refers to

a gender identity or role performance that matches society's expectations based on biological sex. For example, a woman who identifies as cisgender would have a vagina and clitoris (biologically female), and would identify as female (gender).

Masturbation

a technique of sexual expression in which a person practices self-stimulation. It is a way for people to learn what they prefer during stimulation and what feels good. Men masturbate by holding and stroking the shaft of the penis. Women find manual stimulation of the clitoris enjoyable, although variations of technique are numerous. Many myths and misinformation surround masturbation. The reality is that people masturbate regardless of sex, age, or marital status. People might not masturbate if they feel guilty about it or believe self-stimulation is wrong. Masturbation is not "dirty" and will not lead to blindness or insanity.

intersex

a term used for a person who is born with biological traits that do not fit into those that traditionally characterize either male or female

LGBTQ

acronym that stands for lesbian, gay, bisexual, transgender, and queer

transgender:

an inclusive term used to describe those who feel that the sex assigned to them at birth incompletely describes or fails to describe them

orgasm:

apex of sexual activity in which rhythmic contractions of the genital organs and many other physiologic changes occur

gender dysphoria:

diagnosis for a person whose biological sex at birth is contrary to the one with which the person identifies

heritage assessment

based on the concept of acculturation and how consistent the client's lifestyle is with the cultural group from which the client originates, or the traditional habits of the client's family's culture. The country or culture of origin has cultural beliefs and practices that are common to that culture, as well as to socioeconomic, ethnic, and religious subgroups within the culture.

ethnocentrism:

belief that one's own ideas, beliefs, and practices are best, superior, or most preferred to those of others; using one's cultural norms as the standard to evaluate others' beliefs

cultural competence:

care delivered with an awareness of the aspects of the patient's culture

sexual dysfunction:

condition that prevents a person or couple from engaging in or obtaining satisfaction from sexual activity

Sex Education

critical to healthy sexual development and safe sexual behaviors. Information received from peers and friends is almost always inadequate and may be erroneous. Parents should be taught to answer children's questions immediately and accurately. Evidence-based, age-appropriate teen pregnancy programs are funded by Congress through Teen Pregnancy Prevention (TPP) Program grants (Office of Adolescent Health, USDHHS, 2017). Abstinence-only programs that do not include more comprehensive approaches have limited (if any) impact on reducing sexual activity. Abstinence-only programs do not influence the number of sexual partners, use of contraceptives, incidence of STIs, or even pregnancy rates. Comprehensive sex education programs improve knowledge, change attitudes and behaviors, and affect outcomes; abstinence-only programs have not been shown to have this positive effec

menopause:

decrease of cyclic hormonal production and cessation of menses in females, usually between ages 45 and 60 years

sexuality:

degree to which a person exhibits and experiences maleness and femaleness physically, emotionally, and mentally encompasses biological sex, sexual activity (including pleasure, intimacy, and reproduction), gender identities and roles, and sexual orientation (World Health Organization [WHO], 2006, 2018a). It involves how a person both exhibits and experiences maleness or femaleness physically, emotionally, and mentally. It includes learned behaviors in how people react to their own sexuality and by how they behave in relationships with others. Cultural, biological, sociopolitical, legal, economic, religious and spiritual, and historical factors influence sexuality (WHO, 2006, 2018a). Sexuality can be an integral part of a person's identity and is present in a person's demeanor through actions, communications, and physical appearance

sexually transmitted infections (STIs):

disease that spreads from one person to another through intimate sexual contact

Biologic Variations

exist among people from different cultural backgrounds, and research is just beginning to help us understand these variations. For example, we now know that differences related to ethnicity/cultural origins cause variations in response to some psychotropic drugs (discussed earlier). Biologic variations based on physical makeup are said to arise from one's race, while other cultural variations arise from ethnicity. For example, sickle cell anemia is found almost exclusively in African Americans, and Tay-Sachs disease is most prevalent in the Jewish community.

subculture:

group of people with different interests or goals than the primary culture a large group of people who are members of the larger cultural group but who have certain ethnic, occupational, or physical characteristics that are not common to the larger culture. For example, nursing is a subculture of the larger health care system culture, and teenagers and older adults are often regarded as subcultures of the general population in the United States. Most societies include both dominant culture groups and minority culture groups. The dominant group has the most ability to control the values and sanctions of the society. It usually is (but does not have to be) the largest group in the society. Minority groups usually have some physical or cultural characteristic (such as race, religious beliefs, or occupation) different from those of the dominant group.

Infibulation:

narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the inner, or outer, labia, with or without removal of the clitoris.

transsexual:

person of a certain biological sex with the feelings of the opposite sex

cisgender

people who identify with the gender that matches the sex assigned to them at birth

Sadomasochism:

practicing sadism and masochism together. It might involve being tied up, biting, hitting, spanking, whipping, pinching, and other activities.

sex

refers to the physical or biological characteristics that distinguish women and men, such as chromosomes, genitals, and hormones

sexual health:

the integration of the somatic, emotional, intellectual, and social aspects of sexual being in ways that are positively enriching and that enhance personality, communication, and love defined as the integration of the somatic, emotional, intellectual, and social aspects of sexual being, in ways that are positively enriching and that enhance personality, communication, and love. Because our sexuality is so basic to our sense of self, nurses need to value sexuality as a critical element of general health and well-being. Nurses must also be skilled in identifying and addressing problems related to sexual self-concept, body image, sexual identity, sexual activity, and sexual discrimination or violence.

Facilitating Coping With Special Sexual Needs

The nurse can help patients cope with sexual concerns generated by diseases and their treatments. See the accompanying Research in Nursing box. Offer anticipatory guidance and information to patients, stressing the importance of open communication with the patient's partner, and also include the partner in teaching. For appropriate patients, start a discussion about possible sexual positions that can reduce pain during coitus. Show the patient drawings of possible sexual positions. Inform the patient that intercourse may be more comfortable if pain medication is taken before beginning sexual activity. When teaching patients about medications, mention any sexual side effects that may occur to prevent anxiety and depression. Patients should alert the health care provider if these side effects occur because often the drug dosage can be modified or the drug changed. If patients are unaware of this, they may discontinue the medication on their own rather than sacrifice sexual functioning, if this is an important aspect of life for them.

Postoperative Education for Patients Who Have Had a Phalloplasty

The nurse instructs the patient about activity, bathing, swelling, hygiene, and sexual activity as described below. Activity •Avoid strenuous activity for 6 weeks •Do not flex at waist more than 90 degrees •Do not lift anything heavier than 5 lb with arm with skin graft donor site Bathing •Lightly sponge bathe for 1 week postoperatively and then begin gently washing penis with warm soapy water •Keep skin graft donor site dry; may use plastic bag to protect from water Swelling •Minor swelling is expected; however, report increased swelling in groin or change in girth of penis to surgeon Hygiene •Wash hands before and after contact with genital area Sexual Activity •Do not use penis for any sexual activities until approved by surgeon (including oral, vaginal, or anal insertion)

Nurses should value sexuality as an important aspect of who the patient is and how the patient is identified as a unique human. Specific patient outcomes to promote sexual health are as follows:

The patient will: Define individual sexuality Establish open patterns of communication with significant others Develop self-awareness and body awareness Describe responsible sexual health self-care practices, identifying appropriate resources Practice responsible sexual expression (e.g., by 5/1/20, the patient will use condoms during all sexual encounters) Specific patient outcomes depend on the nature of the patient's problem or concern. Expected outcomes should be patient-oriented—that is, something the patient desires to do or has the ability to accomplish. For example, it is not enough to advise a method of birth control; rather, the nurse needs to know which method the patient is motivated and able to use.

Developmental Considerations

The process of human development affects the psychosocial, emotional, and biological aspects of life, which in turn affect a person's sexuality. Biological sex is the only distinguishing trait present at conception. From birth onward, biological sex and gender influence behavior throughout life. Table 45-1 on pages 1754-1755 summarizes sexuality throughout the life span and the nursing implications for each stage.

Health risks for LGBTQ

The root cause of health risks or disparities among people who are LGBTQ is stigma (i.e., negative and unfair beliefs). For reasons beyond the scope of this chapter, people learn to stigmatize some human differences such as skin color and sexual orientation, whereas other differences are not stigmatized, such as eye color or left-handedness (Eliason & Chinn, 2018). People who are LGBTQ have historically been viewed as different or deviant, which is known as stigmatization. The stigma of people who are LGBTQ has led to many social effects, such as lack of recognition of relationships and family, the right to adopt, hate crimes and violence, discrimination in employment and education, and discrimination in housing (Eliason & Chinn, 2018). A person who is LGBTQ does not experience health risks simply because they identify as gay, lesbian, bisexual, or transgender; the stigma associated with their LGBTQ identity is what puts them at risk for certain health disparities. As compared to people who are heterosexual and cisgender, people who are LGBTQ are at greater risk for certain physical and mental health issues. In terms of mental health disorders, people who are LGBTQ have a higher rate of depression and anxiety (Bostwick, Hughes, Steffen, et al., 2019; Ross, Salway, Tarasoff, et al., 2018; Witcomb, Bouman, Claes, et al., 2018) and experience more suicidality (Lyons, Walters, Jack, et al., 2019; McNeil, Ellis, & Eccles, 2017). Nearly 50% of people who are transgender have reported suicide attempts. Moreover, people who are LGBTQ tend to experience more victimization, such as physical or verbal harassment, which is associated with higher rates of depression and suicidality (Burks, Cramer, Henderson, et al., 2018). Women who are lesbian, bisexual, or queer tend to be at greater risk for obesity and cardiovascular disease as compared to heterosexual women (Simoni, Smith, Oost, et al., 2017). Obesity in women who are lesbian, bisexual, or queer is linked to dysregulated eating, such as emotional- or binge-eating. The causes of dysregulated eating are complex and include biological, psychological, and social factors. In women who are lesbian, bisexual, or queer, stigma is one of the root causes of obesity. Stigmatizing experiences, such as discrimination or victimization, leads to emotional distress, which in turn is associated with dysregulated eating as a coping strategy (Mason, Smith, & Lavender, 2019) (see Chapter 42 for further discussion on obesity). Men who are gay or bisexual and transgender women have higher rates of infection with the human immune deficiency virus (HIV) as compared to the general population. Men who are gay or bisexual is the population most affected by HIV in the United States (Centers for Disease Control and Prevention [CDC], 2019a). People who are transgender receive an HIV diagnosis at three times the rate of the national average (CDC, 2019b). Among these populations, rates of HIV are even higher among certain subgroups, especially people who are African American and young adult (see Chapter 32 for further discussion on HIV).

Ethnocentrism

The universal tendency of humans to think their ways of thinking, acting, and believing are the only right, proper, and natural ways.

Worldview

The way individuals or groups of people look at the universe to form basic assumptions and values about their lives and the world around them; includes cosmology, relationships with nature, moral and ethical reasoning, social relationships, magicoreligious beliefs, and aesthetics.

Massage therapy

Therapeutic stroking or kneading of the body to decrease pain, produce relaxation, and/or to improve circulation to that body part

ASKED mnemonic

(awareness, skill, knowledge, encounters, and desire) to examine your cultural competence (from Campinha-Bacote's website). Ask yourself how aware you are of your own biases and prejudices toward people different from you. Ask yourself if you can complete a cultural assessment being sensitive to cultural differences and sensitivities. Ask yourself how much you know about different cultures and ethnic groups, about their beliefs, customs, and biologic variations. Ask yourself what level of interest you have in interacting with people from different cultures or ethnicities. Finally, ask yourself if you really have interest in becoming culturally competent

previous pain experiences

A child identifies pain based on his or her experiences with pain in the past. The number of episodes of pain, the type of pain, the severity or intensity of the previous pain experience, the effectiveness of treatment of pain, and how the child responded all affect how the child will perceive and respond to the current experience. Research suggests that severe pain experiences in the neonate or young infant can lead to sensory disturbances and altered pain responses lasting into adulthood (Anand, 2019). Previous pain experiences with inadequate pain control may lead to increased distress during future painful procedures. For example, research studies have demonstrated that neonates who had undergone painful procedures such as circumcision and heel lancing showed a stronger negative response to routine immunizations and venipuncture weeks to months later

Cultural Diversity

An appreciation for the diverse characteristics and needs of people from varied ethnic and cultural backgrounds is important in health care and nursing. Some projections indicate that by 2030, racial and ethnic minority populations in the United States will triple. The latest U.S. census classified five distinct races as White, Black or African American, Asian, Native American or Alaska Native, and Native Hawaiian/Pacific Islander. The Asian race had the largest growth rate among these five racial groups. The Hispanic population, classified primarily under the White race, was noted to account for more than half of the increased population growth. The non-Hispanic Caucasian population will proportionally decrease so that they will no longer comprise the majority population, and other ethnic and racial minority populations will collectively comprise the majority of all Americans by approximately 2044 (Colby & Ortman, 2015). As the cultural composition of the population changes, it is increasingly important to address cultural considerations in the delivery of health care. Patients from diverse sociocultural groups not only bring various health care beliefs, values, and practices to the health care setting but also have unique risk factors for some disease conditions and unique reactions to treatment. These factors significantly affect a person's responses to health care problems or illnesses, to caregivers, and to the care itself. Unless these factors are assessed, understood, and respected by nurses, the care delivered may be ineffective, and health care outcomes may be negatively affected

Food Intake

At times, a combination of physiologic and physical factors that influence nutrient requirements and, or in combination with, sociocultural and psychosocial factors can affect a person's nutritional intake. Subsequently, these factors can result in a decrease or increase in food intake.

Homeopathy

Based on the theory of "like treats like"; helps restore the body's natural balance

Rootwork

Belief that illnesses are supernatural in origin (witchcraft, voodoo, evil spirits, or evil person). Anxiety, gastrointestinal complaints, fear of being poisoned or killed.

Population Demographics

Changes in the population in general are affecting the need for and the delivery of health care. According to the United States (U.S.) Census Bureau (2020), over 329 million people reside in the country. Not only is the population increasing, but its composition is also changing. The decline in birth rate and the increase in lifespan have resulted in proportionately fewer school-age children and more senior citizens, many of whom are women. Much of the population resides in highly congested urban areas, with a steady migration of members of ethnic minorities to urban settings. Poverty is a growing concern. According to the U.S. Department of Housing and Urban Development's (HUD's) 2019 Annual Homeless Assessment Report, on a given night, approximately 568,000 individuals were documented as homeless in the United States. Homelessness increased by 3% from 2018 to 2019, with almost 40% of this population staying on the streets or other unsheltered locations; in addition, a higher percentage of minority populations compared to the total U.S. population are impacted by homelessness today (U.S. Department of Housing and Urban Development, 2020).

The characteristics of culture include the following:

Culture helps shape what is acceptable behavior for people in a specific group. It is shared by, and provides an identity for, members of the same cultural group. Culture is learned by each new generation through both formal and informal life experiences. Language is the primary means of transmitting culture. The practices of a particular culture often arise because of the group's social and physical environment. Cultural practices and beliefs may evolve over time, but they mainly remain constant as long as they satisfy a group's needs. Culture influences the way people of a group view themselves, have expectations, and behave in response to certain situations. Because a culture is made up of people, there are differences both within cultures and among cultures.

Sexual dysfunction to assessment priorities

Each person is born with a certain amount of sexual drive, which if overdrawn in youth leaves little reserve for later years. Actually, the correlation between sexual activity and length of time it persists throughout life is just the opposite. The more consistently sexually active a person is, the longer the activity continues into the later years of life. A person's need for sexual expression becomes less important in the latter half of life. Physiologically, sexual desire and ability do not decrease markedly after middle age. The expression of sexuality as an integral part of development follows the overall pattern of health and physical performance. Sexual abstinence is necessary in training for sports. Physiologically, the achievement of orgasm is rarely more demanding than most activities encountered in daily life. The desire for sleep that often follows is most commonly due to factors other than physical exhaustion from sexual activities. There is no scientific evidence that sex "weakens" a person. Excessive sexual activity can lead to mental illness. The biologic significance of human sexuality has no greater effect on total development than any other necessary biologic function. There is no scientific basis for believing that a person will develop a mental or physical illness with excessive or no sexual activity. "Wet dreams" are indicators of sexual disorders. Erotic dreams that culminate in orgasms are normal and common physiologic phenomena in at least 85% of men. They can occur at any age after puberty. Some women also report in clinical studies that their sexual dreams culminate in orgasm. In women, this phenomenon is believed to increase with advancing age. Because of the anatomical nature of the sex organs, women are passive and men are aggressive. Physiologic studies disprove this myth by showing women to be far from passive. Maximum gratification requires each partner to be both passive and aggressive in participating mutually and cooperatively. It is unnatural for a woman to have as strong a desire for sex as a man. Women should not enjoy sex as much as men. These myths have been reinforced by a society that has traditionally taught women that they are to suppress sexual desires to gain love, security, and social respect, based on the assumption that it is the basic nature of women to be submissive, dependent, and subordinate. Physiologic studies indicate that, in some respects, a woman's sex drive is not only as strong, but may be even stronger than that of a man. Women who have multiple orgasms or who readily come to climax are nymphomaniacs or promiscuous. Physiologic studies suggest that we do not know women's sexual potential; these studies indicate that there is a wide range of intensity and duration of orgasmic experience, and the potential for multiple or frequent orgasms within a brief period is not at all uncommon. Therefore, women normally may have greater orgasmic capacity than men with regard to duration and frequency of orgasm. There is a difference between vaginal orgasm and clitoral orgasm. Physiologic misunderstanding has produced the myth of separate clitoral and vaginal orgasms rather than their interrelations. Female orgasm is normally initiated by clitoral stimulation, but because orgasm is a total body response, there are marked variations in intensity and timing. There is no reason to believe that the female response to the sex act is due to a vaginal rather than a clitoral orgasm. A mature sexual relationship requires both partners to achieve simultaneous orgasm. Although simultaneous orgasm may be desirable, it is unrealistic. Often, it is possible only under the most ideal circumstances and is not a determinant of sexual achievement or of satisfaction (except to someone who accepts this as dogma). The larger penis has greater possibilities for producing orgasm in the woman. Physiologically, there is practically no relation between the size of a man's penis and his ability to satisfy a woman sexually. Furthermore, there is little correlation between penile size and body size and their relation to sexual potency. The face-to-face coital position is the proper, moral, and healthy one. Knowledge of human sexual practices dispels this myth with the recognition that there is no normal or single most acceptable sexual position. Whatever position offers the most pleasure and is acceptable to both partners is correct for them. Any variation is normal, healthy, and proper if it satisfies both partners. The ability to achieve orgasm is an indicator of a person's sexual responsiveness. Achievement of a satisfactory sexual response is the result of numerous physical, psychological, and cultural influences. Too often, the physical fact of orgasm (or lack of orgasm) is taken to be symbolic of sexual responsiveness and seen out of context of the entire relationship.

Implementing

Establishing a Trusting Nurse-Patient Relationship It is impossible to address a patient's sexuality if trust has not been developed between you and the patient (see Through the Eyes of a Student). To develop trust, project an objective, nonthreatening, and nonjudgmental attitude, and emphasize that the information the patient gives will be kept confidential. You need to be aware of your own behavior and verbal and nonverbal cues. You also need to anticipate the patient's concerns in order to help the patient trust you with information of an intimate nature. Be sure to establish respect for the patient and empathy before discussing sexual issues. Consider all of the patient's circumstances and life experiences using a therapeutic approach. Only when you are accepted as a trusted, caring person will the patient reveal details of his, her, or their private life, including sexual concerns. Teaching About Sexuality and Sexual Health Most nursing interventions pertaining to a patient's sexuality involve teaching to promote sexual health. Major goals of patient teaching involve effecting change in knowledge, attitude, or behavior. In some situations, patients need help defining or redefining their sexuality and its importance to their lives. Offering information, dispelling fears, and providing positive reinforcement are some ways to help patients increase their knowledge about their bodies and sexual functioning. Patients may need assistance in modifying behaviors or learning new skills to increase the quality of sexual health and functioning. See the Promoting Health Literacy box. Part of teaching also includes correcting sexual myths and promoting body awareness. Many people believe things about sex that they have heard from family or friends that are not true or are not based on scientific data. During the assessment, or while providing care, take the opportunity to refute sexual myths and teach factual information (Table 45-4 on page 1772). Patients may need assistance in becoming familiar with what they believe and feel about their sexual selves. Be helpful to patients who have difficulty accepting or developing their sexuality by promoting their self-confidence and a good self-concept. When patients feel comfortable about themselves and their sensual feelings, they can begin to focus on how they feel about their sexual functioning and specific sexual expressions. Getting to know your physical body is important to healthy sexual development. All people, sexually active or not, need to be aware of the appearance of their genitalia. Some people, because of their background, feel ashamed and repulsed by their bodies; others feel that touching the body is dirty and may feel guilt and anxiety in stimulating themselves. Patients need assistance in improving body awareness if any of these issues are present. Patients can become accustomed to looking at their bodies by looking at nonthreatening anatomy first and then proceeding to the genitals. This can be done in the shower or with the use of a mirror. Knowing what looks normal can be of great importance so that patients can report the development of an unusual appearance later. After patients have developed some degree of comfort in looking at their bodies, they can progress to experiencing touch. Again, patients should progress from nonthreatening parts of the body until the genitals can be touched without stress. A good exercise for women in developing body awareness is the use of Kegel exercises. These exercises promote good vaginal tone by localizing and strengthening the pubococcygeal muscle. A woman can locate this muscle by stopping a stream of urine midway through urination. Contracting this muscle can be repeated at any time of the day in any circumstance because its performance is undetectable. Some women who practice Kegel exercises have found that their sexual satisfaction is improved.

General Routine Screening versus Focused Specialty Assessment of Culture

Every nurse-client encounter needs to include a cultural assessment, as culture affects every part of a person's health status. The degree to which cultural assessment occurs depends on the nurse's expertise and cultural experiences (Fig. 11-4). It is important to dialogue with clients to learn about their culture and cultural preferences. Next, the nurse should refer to literature to learn more about the client's culture as needed to provide culturally competent nursing care.

Skin, Hair, Nails

Fair-skinned people, especially those with light eyes and freckles, are at highest risk for developing skin cancers, although all people who are exposed to high levels of intense sunlight are at risk. Because ozone depletion is a factor in skin cancer risk, people living in Australia and southern Africa are at greater risk. Worldwide, 2 to 3 million nonmelanoma and 132,000 melanoma skin cancers occur each year (WHO, 2017). Although darker skin is not as susceptible to skin cancers, some other skin conditions occur more frequently in darker-pigmented people (Skin of color, 2006). Darker-skinned people come from many ethnic and geographic groups including African Americans, Native Americans, Asians, and Latinos or Hispanics. The conditions that are more common in darker skin are postinflammatory hyperpigmentation, vitiligo, pityriasis alba, dry or "ashy" skin, dermatosis papulosanigra (flesh moles), keloids, keloid-like acne from shaving the neck, and hair loss (in cases of tightly curled and fragile hair and use of relaxers or tight rollers).

Illness (Asia)

Fear of wind, cold exposure causing loss of yang energy.

Ghost sickness (Navajo)

Feelings of danger, confusion, futility, suffocation, bad dreams, fainting, dizziness, hallucinations, loss of consciousness. Possible preoccupation with death or someone who died.

Hispanic (Mexican, Central and South America, Spain/Portugal) traditions

Folk healers (curandero/a, bruja/o [witch], yerbero/a, partera [midwife]) Hot/cold balance for diet, herbs, amulets, prayers to God and saints and spiritual reparations for sins, avoiding "evil eye" caused by jealousy and envy

Native Americans and Alaska Natives

Heart disease Cirrhosis of the liver Diabetes mellitus Fetal alcohol syndrome

Asians

Hypertension Cancer of the liver Lactose intolerance Thalassemia

African Americans

Hypertension Stroke Sickle cell anemia Lactose intolerance Keloids

Additional Sociocultural Factors Affecting Nutritional Intake

In addition to the previously mentioned factors, consider the following issues to determine their impact on a patient's nutritional status (Dudek, 2018): Illiteracy Language barriers Knowledge of nutrition Lack of caregiver or social support Social isolation Limited ability to obtain or purchase food Lack of or inadequate cooking and/or food preparation arrangements

Family Support

In many cultural and ethnic groups, people have large, extended families and consider the needs of any family member to be equal to or greater than their own. They may be unwilling to share private information about family members with those outside the family (including health care providers). Other cultural groups have great respect for the elders in the family and would never consider institutional care for them. Including the family in planning care for any patient is a major component in nursing care to meet individualized needs, especially if those needs can be met only through consideration of all members of the family.

temperament

Literature suggests that temperament plays a role in predicting distress and pain levels in a child during painful events (Horton et al., 2015; Martin & Cohen, 2012). For example, a child with a "difficult temperament" is more likely to have an increased distress response to pain. Nurses can personalize interventions in the clinical environment and during the pain experience to better fit the child's temperament and other personality traits of the child and family.

Socioeconomic Factors

Low income is a major problem in the United States and is often described as having created a culture of poverty. A report from the U.S. Census Bureau (2014) noted that an estimated 15% of the U.S. population had an income below the poverty threshold. Of that population, the lowest income was found in African Americans, Native Americans, and Alaska Natives. In 2014, 21% of all children (15.5 million) lived in poverty—that's about 1 in every 5 children. On a single night in January 2016: An estimated 194,716 people in families, or 61,265 family households were identified as homeless. More than 19,000 were living on the street, in a car, or in another place not meant for human habitation. 120,819 were children under the age of 6 (National Alliance to End Homelessness, n.d.). There has been much debate about how to define poverty. In terms of economics, a person or family whose income falls below an established poverty line is considered poor. The U.S. Census Bureau defines poverty according to money or income guidelines that vary by family size and composition. If the family's total income is less than a set threshold, all members of the family are considered poor. Others have stated that poverty is a relative term that reflects a judgment based on community standards. Such standards vary at different times and in different places; what is judged to be poverty in one community might be regarded as wealth in another (Spector, 2013). No matter how poverty is defined, it is an increasingly devastating epidemic, fueled by real estate foreclosures and credit debt that has evolved into a culture of its own. At highest risk are children, older people, families headed by single mothers, and the future generations of those now living in poverty. Access to financial resources affects how individuals and families meet their basic needs and maintain their health. Poverty often leads to problems such as lack of health insurance, inadequate care of infants and children, lack of access to basic health care services, and homelessness. All these are of concern to nursing. The feminization of poverty threatens to increase the number of people who are living at poverty level. The number of female-headed households is increasing as a result of divorce, abandonment, unmarried motherhood, and changes in abortion laws. Because it is now common that two incomes are required in a household for economic survival, a single woman supporting a household is at a financial disadvantage. The number of single-parent families headed by women is associated closely with the increasing number of children living in poverty and the number of homeless families with children. The increasing population of older people has also raised problems associated with poverty. Many older people live on fixed incomes that often do not keep up with inflation, and many (particularly widows) are on the borderline of poverty or have already slipped below the poverty level. Socioeconomic status often differs by the cultural group of the older adult. For example, Pacific/Asian, African-American, Native American, and Hispanic elders generally have lower incomes than elders in the majority population. The work history of the cultural group, especially those who have labored all their lives as agricultural workers, often means that a person has no Social Security or Medicare benefits. In some cases, the culture of poverty is passed from generation to generation. This appears to be especially true in such groups as migrant farm workers, families living on public assistance, and people who live in isolated areas such as Appalachia. Poverty cultures often have the following characteristics: Feelings of despair, resignation, and fatalism "Day-to-day" attitude toward life, with no hope for the future Unemployment and need for financial or government aid Unstable family structure, possibly characterized by abusiveness and abandonment Decline in self-respect and retreat from community involvement Poverty has long been a barrier to adequate health care. It prevents many people from consistently meeting their basic human needs. The lack of affordable or adequate housing is a problem experienced frequently by poor people. When low-income housing is available, it sometimes lacks such necessities as running water, heat, and electricity. To stretch their available money and to pool resources, many poor people live in crowded conditions, with several families living together in one household. Research has demonstrated that crowded living conditions foster depersonalization, correlate with higher crime rates, and lead to psychological problems such as schizophrenia, alienation, and feelings of worthlessness (Spector, 2013). Such conditions also contribute to an increased incidence and severity of disease and illness because of the closer proximity of people, the sharing of utensils and belongings, poor sanitation, and poor health habits. Accessing health care facilities frequently requires transportation, which often is neither affordable nor available to poor people. Their access to health insurance also is frequently limited, and they often must choose between purchasing food and obtaining health care. Those in upper-income groups tend to live longer and to experience less disability than those in lower-income groups. Other barriers to health care include isolation, language or communication difficulties, seasonal occupations, migration patterns, depersonalization, and institutional prejudice

Medication

Many drugs have the potential to influence nutrient requirements. Nutrient absorption may be altered by drugs that (1) change the pH of the GI tract, (2) increase GI motility, (3) damage the intestinal mucosa, or (4) bind with nutrients, rendering them unavailable to the body. Nutrient metabolism can be altered by drugs that (1) act as nutrient antagonists, (2) alter the enzyme systems that metabolize nutrients, or (3) alter nutrient degradation. Some drugs alter the renal reabsorption of nutrients and, therefore, may increase or decrease nutrient excretion.

Native American/Alaska Native traditions

Medicine men or shamans Respect for nature and avoid evil spirits, use masks, herbs, sand paintings, amulets

CULTURAL INFLUENCES ON GROWTH AND DEVELOPMENT

Many cultural differences have an impact on growth and development. For instance, certain ethnic groups tend to be shorter than others because of their genetic makeup (Sinha, 2019). These children will not grow to be as tall as those of another ethnic background. Cultural feeding practices in some cultures may lead to overweight in some children. Some cultures and certain religions advocate vegetarianism; those children need nutritional assessment to ensure they are getting enough protein intake for adequate growth. Parenting styles and health promotion behaviors can also be significantly influenced by culture. Parents and extended family are the most significant influences in an infant's life in most cultures. Certain cultures place a high value on independence and may encourage their infants to develop quickly, while other cultures "baby" their infants for longer periods. In most cultures, the mother takes primary responsibility for caring for the child, but in some cultures, major health-related decisions may be deferred to the father or grandparents. Health beliefs are often strongly influenced by an individual's religious or spiritual background. Sometimes this creates conflict in the health care setting when the health providers have a different value system than that of the infant's family. In some cultures, infants and children share a bed with their parents. When an infant or child is hospitalized and is accustomed to sleeping with the parents, it may be difficult and distressing for him or her to try to sleep alone. The nurse should explore the family's cultural practices related to growth and development. Usually, these practices are not harmful and can be supported by the health care team, but safety must always be considered. The nurse should not make assumptions about a family's cultural practices based on their skin color, accent, or name; rather, the nurse should perform an adequate assessment

Caida de la mollera

Mexican term for fallen fontanel. Thought to be caused by midwife failing to press on the palate after delivery; falling on the head; removing the nipple from the baby's mouth inappropriately; failing to put a cap on the newborn's head. Crying, fever, vomiting, diarrhea are thought to be indications of this condition (note the similarity to dehydration).

Health Care for Those Who Identify as LGBTQ

Nurses working with those who identify as LGBTQ should consider that these people: •Are found in every ethnic group and socioeconomic class. •Are seen in all age groups, including teens and seniors. •Can be single, celibate, or divorced. •Have often encountered insensitivity in health care encounters. •Are typically offered contraception when asked if they are sexually active and respond affirmatively, as health care providers may assume incorrectly that they practice heterosexual intercourse. •Have lower health screening rates than other women. •Often feel invisible and underuse health care, similar to many other marginalized groups of women. Nurses need to: •Use gender-neutral questions and terms that are nonjudgmental and accepting. •Recognize that lesbian teens are at risk for suicide and screen for those at risk. •Recognize that many lesbians do participate in heterosexual activity but consider themselves at low risk for STIs. Because human papilloma virus, herpes infections, and other organisms implicated in STIs are transmitted by secretions and contact, lesbians may need information on STIs and contraception. If sex toys are used and not cleaned, pelvic infections can occur. Women who identify as LGBTQ are at high risk for cancer, heart disease, depression, and alcohol abuse. They may have a higher body mass index, may bear fewer or no children, and often have fewer health preventive screenings than women who are heterosexual. These factors may increase the risk of colon, endometrial, ovarian, and breast cancer, as well as cardiovascular disease and diabetes. Adolescents are at risk for smoking and suicide/depression.

Amok (Malaysia)

Occurs among males (20-45 years old) after perceived slight or insult. Aggressive outbursts, violent or homicidal, aimed at people or objects, often with ideas of persecution. Amnesia, exhaustion, finally, return to previous state.

Shifting

Pain moves from one area to another, such as from the lower abdomen to the area over the stomach.

gender dysphoria

People who experience discomfort or distress because their biological sex at birth is contrary to the gender they identify distress a person feels due to a mismatch between their gender identity and sex assigned at birth

prohibited foods and beverages for judaism

Pork Predatory fowl Shellfish and scavenger fish (e.g., shrimp, crab, lobster, escargot, catfish). Fish with fins and scales are permissible. Mixing milk and meat dishes at same meal Blood by ingestion (e.g., blood sausage, raw meat). Note: Packaged foods will contain labels identifying kosher ("properly preserved" or "fitting") and pareve (made without meat or milk) items.

Education for Patients undergoing ambulatory surgery

Preoperative education for the same-day or ambulatory surgical patient comprises all previously discussed patient education as well as collaborative planning with the patient and family for discharge and follow-up home care. The major difference in outpatient preoperative education is the environment. Preoperative education content may be presented in a group class, in a media presentation, at PAT, or by telephone in conjunction with the preoperative interview. In addition to answering questions and describing what to expect, the nurse tells the patient when and where to report, what to bring (insurance card, list of medications and allergies), what to leave at home (jewelry, watch, medications, contact lenses), and what to wear (loose-fitting, comfortable clothes; flat shoes). The nurse in the surgeon's office may initiate education before the perioperative telephone contact. During the final preoperative telephone call, education is completed or reinforced as needed and last-minute instructions are given. The patient is reminded not to eat or drink for a specified period of time and about skin cleansing techniques prior to surgery (see later section on preparing the skin).

Garlic (Allium sativum)

Reported to lower BP and cholesterol levels Can increase bleeding

Koro (Malaysia, Southeast Asia)

Similar to conditions in China, Thailand, and other areas. Fear that genitalia will retract into the body, possibly leading to death. Causes vary, including inappropriate sex, mass cases from belief that eating swine flu-vaccinated pork is a cause.

Oral-Genital Stimulation

Stimulation of the genitals by the mouth and tongue might be used during foreplay or as a way to reach orgasm. Cunnilingus is stimulation of the female genitals by licking and sucking the clitoris and surrounding structures. Fellatio is stimulation of the male genitals by licking and sucking the penis and surrounding structures. One partner or both may use these techniques simultaneously (commonly known as "69" or "sixty-nine"). Younger people may use oral-genital stimulation as a replacement for vaginal intercourse to avoid pregnancy.

Falling out or blacking out

Sudden collapse preceded by dizziness, spinning sensation. Eyes may remain open but unable to see. May hear and understand what is happening around them but unable to interact.

Sexual intercourse

The act of intercourse (coitus or copulation) is the insertion of the penis into the partner's vagina, anus, or mouth. It usually begins by stimulation of the senses in some way, followed by a period of activity known as foreplay. "Petting" is part of foreplay; it can involve simple stroking of the breasts, arms, back, and neck without genital involvement or may lead to mutual masturbation and orgasm.

Cultural relativism

The belief that the behaviors and practices of people should be judged only from the context of their cultural system.

Questioning refers to

a person who is unsure of his/her/their sexual orientation.

questioning

a person who is unsure or is still exploring their sexual orientation or is concerned about applying a social label to themselves

Asexual refers to

a person who lacks romantic or sexual attraction to others.

Transsexual refers to

a person who lives full-time as a member of a gender that differs from the sex and gender he/she/they were assigned at birth. This term sometimes specifically refers to those transitioning with hormones or confirmation surgery.

Sexual identity encompasses

a person's self-identity, biological sex, gender identity, gender role behavior or expression, and sexual orientation

Health Care

describes services that are offered to individuals, families, and communities to help them maintain health and wellness, prevent and manage illness and complications, and provide support through rehabilitation, recovery, and transitions to palliative care. Health care can be provided in inpatient, outpatient, and community settings by a variety of health professionals, including but not limited to nurses, primary providers, pharmacists, dieticians, social workers, psychologists, and physical, occupational, speech and respiratory therapists.

cisgender:

gender identity or role performance that matches society's expectations based on biological sex

heterosexual:

having sexual feelings for a person of the opposite sex

Female genital mutilation (FGM),

includes procedures that intentionally injure or alter the female genital organs for nonmedical reasons. It is a procedure that has no health benefits for girls and women and can cause severe bleeding and problems urinating. Later in life it can cause cysts, infections, and infertility, as well as complications in childbirth and increased risk of newborn deaths. About 200 million girls and women worldwide, primarily in Africa, the Middle East, and Asia, are currently living with the consequences of FGM. The WHO (2018b) writes that: "FGM is recognized internationally as a violation of the human rights of girls and women. It reflects deep-rooted inequality between the sexes, and constitutes an extreme form of discrimination against women. It is nearly always carried out on minors and is a violation of the rights of children. The practice also violates a person's rights to health, security, and physical integrity, the right to be free from torture and cruel, inhuman or degrading treatment, and the right to life when the procedure results in death" (para. 3).

Biological sex is

the term used to denote chromosomal sexual development: male (XY) or female (XX), external and internal genitalia, secondary sex characteristics, and hormonal states.

Excision:

partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora

Clitoridectomy:

partial or total removal of the clitoris and, in very rare cases, only the prepuce (the fold of skin surrounding the clitoris)

queer

people who are romantically, emotionally, or sexually attracted to numerous genders (male, female, transgender, intersex, etc.) or people who identify as nonheterosexual but do not want to use labels, such as gay, lesbian, or bisexual

Time

perceived to be measurable (Western cultures) or fluid and flowing (Eastern cultures). Different cultural groups tend to place different values on the past versus present versus future. Those focused on the past value practices that are unchanged from those of ancestors and are often resistant to new ways. Those focused on the present perceive what is happening in the present to be more important than what will occur in the future. For instance, if a person has an appointment with you but is involved in a pleasurable activity at that time, then either the appointment will be missed or the person will arrive late. Those who are future oriented place value on deferring pleasure for a later gain. They are the ones who will value the care and treatment in expectation of improvement (this reflects Western values).

menstruation:

periodic discharge of bloody secretions through the vagina; usually for 4 to 5 days each month

Providing culturally respectful nursing care means that care is

planned and implemented in a way that is sensitive to the needs of individuals, families, and groups from diverse populations within society.

transition

process of aligning a person's gender expression with their self-identified gender identity, which can include social, medical, surgical, and legal changes

sexual orientation

umbrella term that refers to romantic, emotional, or sexual attraction to persons of the opposite gender, the same gender, or to both or more than one gender

transgender

umbrella term used to describe the full range of people whose gender identity does not match with the sex assigned to them at birth

Steps to Developing Cultural Competence and Humility

1. Cultural Self-Awareness • Become aware of, appreciate, and become sensitive to the values, beliefs, customs, and behaviors that have shaped one's own culture. • Engage in self-exploration beyond one's own culture and "see" clients from different cultures. • Health care has a multicultural environment. • Practice self-reflection of your own identity. • Cultural diversity is awareness of the presence of differences among clients. • Examine personal biases and prejudices toward other cultures. • Become aware of differences in personal and clients' backgrounds. 2. Cultural Knowledge • Obtain knowledge about various worldviews of different cultures, such as through reading about different cultures, attending continuing education courses on different cultures, accessing websites, and attending cultural diversity conferences. • Become familiar with culturally/ethnically diverse groups, worldviews, beliefs, practices, lifestyles, and problem-solving strategies. 3. Cultural Skills • Learn how to perform a competent cultural assessment. • Ask each client about their identity first before starting any interaction. • Assess each client's unique cultural values, beliefs, and practices without depending solely on written facts about specific cultural groups. • Embracing ethics empowers mutual respect, equality, and trust. 4. Cultural Encounter • Listen more than you speak. • Engage in cross-cultural interactions with people from culturally diverse backgrounds, such as attending religious services or ceremonies and participating in important family events. • Participate in as many cultural encounters as possible to avoid cultural stereotyping.

Enculturation

A natural conscious and unconscious conditioning process of learning accepted cultural norms, values, and roles in society and achieving competence in one's culture through socialization.

Pain management

A pain assessment should include differentiation between acute and chronic pain. A pain intensity scale should be introduced and explained to the patient to promote more effective postoperative pain management. (See Chapter 9 for examples of pain scales.) Preoperative patient education also needs to include the difference between acute and chronic pain so that the patient is prepared to differentiate acute postoperative pain from a chronic condition such as back pain. Preoperative pain assessment and education for the older patient may require additional attention Postoperatively, medications are given to relieve pain and maintain comfort without suppressing respiratory function. The patient is instructed to take the medication as frequently as prescribed during the initial postoperative period for pain relief. Anticipated methods of administration of analgesic agents for inpatients include patient-controlled analgesia (PCA), epidural catheter bolus or infusion, or patient-controlled epidural analgesia (PCEA; see Chapter 9 for discussion of PCA and PCEA). A patient who is expected to go home will likely receive oral analgesic agents. These methods are discussed with the patient before surgery, and the patient's interest and willingness to use them are assessed.

Boufeedeliriante (Haiti) Zar (Ethiopia, Somalia, Egypt, Sudan, Iran, and other North African and Middle Eastern countries)

A panic disorder with sudden agitated outbursts, aggressive behavior, confusion, excitement. May have hallucinations or paranoia. Spirit possession with symptoms such as dissociative episodes with laughing, shouting, hitting the head against a wall, singing, or weeping; may show apathy or withdrawal; may refuse to eat or participate in activities of daily living; may develop long-term relationship with possessing spirit. Not necessarily considered pathologic in the culture.

Interpersonal environment

A patient's ethnicity and support system are considered when obtaining a health history. Attitudes and beliefs about health, illness, health care, hospitalization, the use of medications, and the use of complementary and alternative therapies, which are derived from personal experiences, vary according to ethnicity. A person from another culture may have different views of personal health practices from those of the health care practitioner (Hogan-Quigley et al., 2017; Weber & Kelley, 2018) (see later discussion on Cultural Assessment). The beliefs, customs, and practices that have been shared from generation to generation are known as ethnic patterns. The influence of these patterns on health-related behaviors and patient's perceptions of health and illness, as well as on how a patient reacts to health problems and interacts with health care providers, cannot be underestimated. Ethnic patterns can be expressed through language, dress, dietary choices, and role behaviors. The following questions may assist in obtaining relevant information: Where did your parents or ancestors come from? When? What language do you speak at home? Are there certain customs or values that are important to you? Do you have any specific practices to keep in good health or for treating illness? Support systems are another important aspect of a patient's interpersonal environment. The evaluation of a patient's family structure (members, ages, and roles), patterns of communication, and the quality of the patient's relationships is an integral part of assessing support systems. Although the traditional family is recognized as a mother, a father, and children, many different types of living arrangements exist within our society. "Family" may mean two or more people bound by emotional ties or commitments. Live-in companions, roommates, and close friends can also play a significant role in a person's support system. Keeping this in mind, nurses should use neutral terms and be sensitive when evaluating family structure. For example, the interview can begin with an open-ended question, such as "Tell me about your family and social support system." Neutral terms should also be used when asking follow-up questions about partners/significant others and parents/guardians

Cultural Influences on Health Supervision

A person's definition of health is influenced by his or her culture. Successful interactions result when the nurse is aware of the beliefs and interactive styles that are often present in members of a specific culture. If the goals of the health care plan are not consistent with the health belief system of the family, the plan has little chance for success. Optimal wellness for the child requires the nurse and the family to negotiate a mutually acceptable plan of care. A plan must balance the cultural beliefs and practices of the family with those of the health care establishment. The nurse must possess cultural competence and sensitivity for the partnership to be successful. Most health promotion and disease prevention strategies in the United States have a future-based orientation, and view the child as an active and controlling agent in his or her own health. This reflects the dominant culture; however, the challenge to the nurse is to develop strategies that are meaningful to children from other cultures. Significant numbers of children belong to cultures with a present-based orientation. These cultures are more concerned about what is going on now. For these children, health promotion activities need shorter-term goals and outcomes to be useful. Children with a fatalistic world view will see any actions on their part as ineffective. They may feel that a god figure or supernatural forces control their fate and that health is a gift to be appreciated, not a goal to be pursued. Certain cultures believe health is the result of being in harmony within oneself and the larger universe. From this viewpoint, taking a medication or receiving a treatment may not be effective ways to restore health because they do not address the problem of being "out of harmony." However, just because an individual belongs to a certain culture does not guarantee that he or she subscribes to all of its values. The nurse should explore each child's specific beliefs during the health interview.

Environment and Support People

A person's environment and the presence or absence of caring support people may also influence the experience of pain. Many people find that the strangeness of the health care environment, especially the lights, noise, lack of sleep, and constant activity of a critical care unit, compounds the experience of pain. The sense of powerlessness that accompanies admission to a health care facility may decrease the person's ability to cope with pain. Depersonalization or separation from a favorite pillow, pet, or source of music may further decrease the person's sense of comfort. For some, the presence of a loved family member or friend is essential to their sense of well-being. Others prefer to be alone when in pain and may become agitated in the presence of a family member. Some patients may use their pain to acquire secondary gains, such as special attention and services from their families. If unchecked, this tendency may lead to resentment and anger in family members and their eventual avoidance of the patient. Intervening and attempting an honest discussion of this problem is important.

Past Pain Experience

A person's experience of pain in the past and the qualities of that experience profoundly affect new pain experiences: Some patients have never known severe pain and have no fear of pain, not realizing how intense the sensation can be. Some patients have experienced severe acute or chronic pain in the past but received immediate and adequate pain relief. These patients are generally unafraid of pain and initiate appropriate requests for assistance. Some patients have known severe pain in the past and were unable to secure relief. Even the suggestion of new pain can lead to acute feelings of fear, despair, and hopelessness. A person whose past pain experience led to correction of unhealthy behavior and produced a greater sense of health and well-being, may respect and value pain and consider the meaning and significance of new pain carefully. In general, people who have experienced more pain than usual in their lifetimes tend to anticipate more pain and exhibit increased sensitivity to pain. Some pain memories are virtually unforgettable. New contact with conditions similar to those that caused the earlier pain can provoke a violent response.

evaluating dietary information

After obtaining basic dietary information, the nurse evaluates the patient's dietary intake and communicates the information to the dietitian and the rest of the health care team for more detailed assessment and clinical nutrition intervention. If the goal is to determine whether the patient generally eats a healthful diet, their food intake may be compared with the dietary guidelines outlined in the USDA's Center for Nutrition Policy & Promotion's MyPlate (Fig. 4-5). Foods are divided into five major groups (fruits, vegetables, grains, protein foods, and dairy), plus oils. Recommendations are provided related to variety in the diet, proportion of food from each food group, and moderation in eating fats, oils, and sweets. A patient's food intake is compared with recommendations based on various food groups for different age groups and activity levels (Weber & Kelley, 2018). If nurses or dietitians are interested in knowing about the intake of specific nutrients, such as vitamin A, iron, or calcium, the patient's food intake is analyzed by consulting a list of foods and their composition and nutrient content. The diet is analyzed in terms of grams and milligrams of specific nutrients. The total nutritive value is then compared with the recommended dietary allowances specific for the patient's age category, gender, and special circumstances such as pregnancy or lactation. Fat intake and cholesterol levels are additional aspects of the nutritional assessment. Trans fats are produced when hydrogen atoms are added to monounsaturated or polyunsaturated fats to produce a semisolid product, such as margarine. Partially hydrogenated oils (PHOs), the primary source of industrially produced trans fats, are found in many popular processed foods, such as baked goods and frozen foods. This is a concern because increased amounts of trans fats have been associated with increased risk for heart disease and stroke. In 2015, the FDA released its final determination that PHOs were not Generally Recognized as Safe (GRAS). At that time, the FDA announced that manufacturers must stop adding PHOs to processed food, providing a 3-year compliance period so that food manufacturers could gradually phase out the use of PHOs. However, to allow for an orderly transition in the marketplace, FDA extended the compliance date for these foods (FDA, 2019).

Prohibited foods and beverages for hinduism

All meats Animal shortenings/fats

BEST PRACTICE:Nonverbal Communication Skills

Although important, nonverbal skills are often underdeveloped, misunderstood, or ignored by health care providers. From 2014 through 2016, workshop training sessions were offered at eight conferences to help participants focus on nonverbal communication skills. Drama exercises were used to enable participants to experiences involving sight, sound, touch, and proxemics in novel ways. Following the workshops, nonverbal communication skills were viewed as important in building trust and relationships with patients. Developing and implementing strategies like this one can enhance providers' communication. Purposeful and specific training that focuses on nonverbal communication skills is likely to be much more effective than a haphazard approach.

Cognitive Coping Strategies

Although some anxiety is common in the surgical setting, untreated or undertreated high preoperative anxiety can lead to complications. Tachycardia, arrhythmias, hypertension, and increased levels of pain have been reported postoperatively in patients with increased preoperative anxiety (Jaruzel, Gregoski, Mueller, et al., 2019). Cognitive strategies may be useful for relieving tension, overcoming anxiety, decreasing fear, and achieving relaxation. Examples of general strategies include: Guided Imagery: The patient concentrates on a pleasant experience or restful scene. Distraction: The patient thinks of an enjoyable story or recites a favorite poem or song. Optimistic Self-Recitation: The patient recites optimistic thoughts ("I know all will go well"). Music Therapy: The patient listens to soothing music (an easy-to-administer, inexpensive, noninvasive intervention). Aromatherapy: The patient inhales aromatic oils to trigger emotional and physical relaxation responses through the olfactory system and brain. Reiki: The practitioner places hands over the patient to (theoretically) transfer energy to promote healing and relaxation. Alternative interventions may include acupuncture, yoga therapy, muscle relaxation, and therapeutic touch.

teens CULTURAL INFLUENCES ON GROWTH AND DEVELOPMENT

Although the adolescent's culture continues to influence him or her, the desire to be in harmony with peers becomes paramount. That desire can cause conflict with the adolescent's family and culture. Today's adolescents live in a rapidly changing, increasingly culturally diverse world. They are exposed to many different cultures and ethnic groups. In 2016, over 49% of children and adolescents in the United States were minorities (Federal Interagency Forum on Child and Family Statistics, 2017). Attitudes regarding adolescence vary among different cultures. Certain cultures may have more permissive attitudes toward issues facing adolescents, while others are more conservative (e.g., toward sexuality). Experiencing a rite-of-passage ceremony to signal the adolescent's movement to adult status varies among cultures. The American culture does not universally have a rite of passage for teenagers. Some religious and social groups do have ceremonies that signal a movement toward the maturity of adulthood (e.g., the Jewish bar or bat mitzvah, the Catholic confirmation, and social debuts). In many parts of the world, separate "youth cultures" have developed in an attempt to blend traditional and modern worlds for the adolescent. It is important for the nurse to recognize the ethnic background of each adolescent. Research has shown that certain ethnic groups are at higher risk for certain diseases. For example, adolescent African Americans are at higher risk for developing hypertension (American Heart Association, 2016). But the major barrier to the adolescent's health and successful achievement of the tasks of adolescence is socioeconomic status. Adolescents at a lower socioeconomic level are at higher risk for developing physical and psychological health care problems and risk-taking behaviors; this may be in part due to their inability to access health care and to obtain needed services (American Psychological Association, 2019). In caring for adolescents, recognize the influence of their culture, ethnicity, and socioeconomic level upon them.

Eye Contact and Face Positioning

Americans expect people talking to each other to maintain a fairly high level of eye contact. Those looking away and not giving "good eye contact" are thought to be rude or inattentive. But people from Eastern countries and Native Americans tend to look down to show respect to the person talking. Also, some African Americans look away when being talked to, but give a very high level of eye contact when speaking. Caucasians unfamiliar with this pattern can get the impression that the person does not care what the caregiver is saying and is aggressive when talking. However, it is just a normal cultural variation in communication pattern. Another variation on positioning is whether persons face each other or stand with the face slightly to the side. American females (both Caucasian and Hispanic American) tend to face each other, but males, and people of some other cultures, tend to stand with the face slightly away from the other speaker.

Pibloktoq or Arctic hysteria (Greenland Eskimos)

An abrupt onset, extreme excitement of up to 30 minutes often followed by convulsive seizures and coma lasting up to 12 hours, with amnesia of the event. Withdrawn or mildly irritable for hours or days before attack. During the attack, may tear off clothing, break furniture, shout obscenities, eat feces, run out into snow, do other irrational or dangerous acts.

Teens dating

An interest in romantic partnerships occurs during adolescence (Fig. 29.5). Some of the reasons cited for this developing interest are physical development and body changes, peer-group pressure, and curiosity. During the past couple of decades, the percentage of 8th through 12th graders that have dated has declined (Child Trends, 2018a). It has been found that 45% of 12th graders, 55% of 10th graders, and 69% of 8th graders have never dated (Child Trends, 2018a). The percentage of teens that date frequently increases with age with 4% of 8th graders, 7% of 10th graders, and 15% of 12th graders reporting going on a date one or more times a week (Child Trends, 2018a). Teen dating can range from group dating to single dating to serious relationships. Most early adolescents spend more time in activities with mixed-sex groups, such as dances and parties, than they do dating as a couple. Popular dating activities today include going out to dinner or the movies, "hanging out" at the mall, or visiting each other's home. During early adolescence, teens tend to date for fun and recreation. Also, they may see dating as a way to upgrade social standing by being seen with a popular or attractive boy or girl, for instance. Middle and late adolescents have group and single dates. Romantic relationships are central to the social life of this age group. By age 18, 70% of adolescents report being in at least one romantic relationship in the past 18 months (Kansky & Allen, 2018). Dating or spending time with a potential romantic partner is viewed as a major developmental marker for teens and is one of the most challenging adjustments. Both positive and negative developmental outcomes can result depending on the quality of the relationship that forms. Some teens who date may report slightly higher levels of self-esteem, self-worth and social support (Kansky & Allen, 2018). However, other types of dating relationships may result in a teen having lower academic success and motivation, having higher depression rates, increased anxiety, and increased risk of substance use (Kansky & Allen, 2018). Trends in dating are changing, but dating remains a developmental milestone for the adolescent. Healthy romantic relationships in adolescence can assist the teen in developing a strong sense of self-identity and developing interpersonal skills, such as empathy, and are related to increased quality of adult relationships (Kansky & Allen, 2018). The emotional ups and downs that accompany dating can help develop emotional resilience and coping skills. Romantic relationships at this stage are a great source of emotional support. Risks of being involved in unhealthy romantic relationships include dating violence and risky sexual activity such as sexually transmitted infections (STIs) and pregnancy. Adolescents do not automatically know what makes for a healthy relationship. They need to be educated on the right and wrong behaviors of dating and what behaviors make up a healthy relationship, such as open communication, honesty, and trust. They need to know the signs of an unhealthy relationship and how to seek help if needed.

Death Rituals

As noted by Purnell (2013), death rituals include views on death and euthanasia along with rituals for dying, burial, and bereavement, and are unlikely to vary from the practices of the client's original ethnic group. Practices that affect health care include such customs as ritual washing of the body, the number of family members present at the death of a family member, religious practices required during or after dying, acceptance of life-or deathprolonging treatments, beliefs about withdrawing life support, and beliefs about autopsy. Responses to death and grief can vary from loud wailing to solemn, quiet grief. In addition, the expected duration of grief varies with culture.

The Nurse's Role in Preventive Care

Applying scientific principles to prevent disease and disability is basic to nursing practice. All health professionals have a special role in health promotion, health protection, and disease prevention. Much of nursing involves prevention, early identification, and prompt treatment of health problems and monitoring for emerging threats that might lead to health problems. Nurses provide health care for women and children at all three levels of prevention. This care often involves advocacy for services to meet their needs.

Providing Optimal Cultural Care

As America is becoming more diverse, nurses must be prepared to care for childbearing families from various cultures. In many cultures, women and their families are cared for and nurtured by their communities for weeks and even months after the birth of a new family member. Cultural humility helps nurses explore cultural competency as a process rather than an outcome. Overall, culturally humble care for all childbearing families includes understanding traditional folk beliefs; involvement and support by family members; respect; presence of a significant other; breastfeeding and healthy eating; observing the principles of hot and cold; avoidance of postnatal sexual intercourse; encouragement; empowerment; the importance of spiritual dimensions; avoidance of evil spirits; and the hope that nurses will anticipate the needs of the mother and infant (Andrews & Boyle, 2019). Box 16.3 highlights some of the major cultural variants during the postpartum period. Nurses need to remember that childbearing practices and beliefs vary from culture to culture. To provide appropriate nursing care, the nurse should determine the client's preferences before intervening. Cultural practices may include dietary restrictions, certain clothes, taboos, activities for maintaining mental health, and the use of silence, prayer, or meditation. Restoring health may involve taking folk medicines or conferring with a tribal healer. A language barrier might interfere with communication between the woman and health providers followed by the health care provider's lack of cultural sensitivity, leading to a woman's reluctance to use health services (Goldman & Trimmer, 2019). Providing culturally diverse care within our global community is challenging for all nurses, because they must remember that one's culture cannot be easily summarized in a reference book but rather must be viewed through one's own life experiences.

COMMUNITY-BASED CARE

As community care for people with physical and mental health problems continues to expand, the nurse's role expands as well. The nurse may become the major caregiver and resource person for increasingly high-risk clients treated in the home and their families and may become more responsible for primary prevention in wellness and health maintenance. Therapeutic communication techniques and skills are essential to successful management of clients in the community. Caring for older adults in the family unit and in communities today is a major nursing concern and responsibility. It is important to assess the relationships of family members, and identifying their areas of agreement and conflict can greatly affect the care of clients. To be responsive to the needs of these clients and their families for support and caring, the nurse must communicate and relate to clients and establish a therapeutic relationship. When practicing in the community, the nurse needs self-awareness and knowledge about cultural differences. When the nurse enters the home of a client, the nurse is the outsider and must learn to negotiate the cultural context of each family by understanding their beliefs, customs, and practices and not judging them according to his or her own cultural context. Asking the family for help in learning about their culture demonstrates the nurse's unconditional positive regard and genuineness. Families from other cultural backgrounds often respect nurses and health care professionals and are quite patient and forgiving of the cultural mistakes that nurses might make as they learn different customs and behaviors. Another reason the nurse needs to understand the health care practices of various cultures is to make sure these practices do not hinder or alter the prescribed therapeutic regimens. Some cultural healing practices, remedies, and even dietary practices may alter the client's immune system and may interact with prescribed medications. The nurse in community care is a member of the health care team and must learn to collaborate with the client and family as well as with other health care providers who are involved in the client's care such as physicians, physical therapists, psychologis and home health aides. Working with several people at one time rather than just with the client is the standard in community care. Self-awareness and sensitivity to the beliefs, behaviors, and feelings of others are paramount to the successful care of clients in the community setting.

Prevention of STIS

As described earlier, STIs are widespread. The only sure way to avoid an STI is to avoid all types of intimate genital contact. When this is impractical, there are other practices that can decrease a patient's risk for STIs (Box 45-1). In the United States, Black women account for most new cases of HIV and AIDS among women. In fact, HIV diagnosis in Black women in 2015 was second only to Black, White, and Hispanic/Latino men who have sex with men (MSM; CDC, 2018a). Most women of color acquire the disease from heterosexual contact, often from a partner who has undisclosed risk factors for HIV infection. A combination of testing, education, socioeconomic support, and brief behavioral interventions can help reduce the rate of HIV infection and its complications among women of color.

Space

As noted by Davis's 1990 classic article on cultural differences in personal space, "everyone who's ever felt cramped in a crowd knows that the skin is not the body's only boundary. We each wear a zone of privacy like a hoop skirt, inviting others in or keeping them out with body language—by how closely we approach, the angle at which we face them, and speed with which we break a gaze" (p. 4). Studies show that Asians and Americans tend to keep more space between them and others when speaking. Latins, both Mediterranean and Latin American, stay closer to each other; and Middle Easterners move in the closest.

People Who Identify as Lesbian, Gay, Bisexual, Transgender, or Queer (LGBTQ)

As the nature of family changes in our society, so must the health care providers' understanding of the people who make up the family unit (Gregg, 2018). Many health assessments presume a heterosexual orientation. Many health care providers are insufficiently prepared to meet the health needs of patients who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ) (see Chapter 54) (Wingo, Ingraham, & Roberts, 2018). Those who identify themselves as LGBTQ may have concerns about disclosure and confidentiality, discriminatory attitudes, and treatment (Gregg, 2018; Wingo et al., 2018) (see Chart 50-5). Some research has reported that transgender people abuse alcohol and drugs to a greater degree than their nontransgender counterparts because their social venues may contribute to alcohol and drug use. Youth who identify as LGBTQ are at higher risk of human immune deficiency virus (HIV) and STIs (Wingo et al., 2018). In addition, youth who self-identify as lesbian, gay, or bisexual or who lack support from parents and families may experience increased physical and mental health issues (e.g., depression, obesity) as well as isolation (Lapinski, Covas, Perkins, et al., 2018). Nurses need to understand the unique needs of this population and provide appropriate and sensitive care.

Preoperative Assessment and Education for Older Adults

Assessment •Assess for allergies and medical comorbidities. •Assess the patient's cognitive and sensory function before the surgeon begins the informed consent process. •Perform a Fall Risk Assessment including the following factors: •History of previous falls •Medication use (e.g., preoperative sedatives) •Level of consciousness (e.g., alert, lethargic) •Ability to follow directions (e.g., cognitive impairment, language barrier) •Sensory impairments (e.g., vision, hearing) •Level of coordination or balance •Toileting needs (e.g., incontinence, frequency, need for assistance) •Presence of external devices (e.g., catheters, drains) •Determine the need for a designated support person or power of attorney to complete the informed consent process. •Review medications to identify potential polypharmaceutical risks to include the following: •Multiple medications •Multiple prescribers •Several filling pharmacies •Too many forms of medications •Over-the-counter medications •Multiple dosing schedules •Document baseline physical assessment parameters, including pain, cardiac rhythm, and oxygen saturation level. •Document a detailed skin assessment with notation of areas of dryness, lesions, or bruising. •Document preoperative fasting status and assess for dehydration, malnutrition, and hypoglycemia. •Perform a psychosocial assessment that addresses fears, anxiety, and feelings of loneliness. •Identify social support to determine whether the patient has home assistance to complete ADLs. Education •Discuss advanced directives and code status to identify the patient's wishes. •Educate the patient about the benefits of controlling pain. •Be prepared to spend additional time, increase the amount of therapeutic touch utilized, and encourage family members to be present to decrease anxiety.

Time

Attitudes about time vary widely among cultures and can be a barrier to effective communication between nurses and patients. Views about punctuality and the use of time are culturally determined, as is the concept of waiting. Symbols of time, such as watches, sunrises, and sunsets, represent methods for measuring the duration and passage of time (Giger, 2016). For most health care providers, time and promptness are extremely important. For example, nurses frequently expect patients to arrive at an exact time for an appointment, although patients may be kept waiting by health care providers who are running late. Health care providers are likely to function according to an appointment system in which there are short intervals. However, for patients from some cultures, time is a relative phenomenon, with little attention paid to the exact hour or minute. Time may also be determined according to traditional times for meals, sleep, and other activities or events. For people from some cultures, the present is of the greatest importance, and time is viewed in broad ranges rather than in terms of a fixed hour. Being flexible in regard to schedules is the best way to accommodate these differences. Value differences also may influence a person's sense of priority when it comes to time. For example, responding to a family matter may be more important to a patient than meeting a scheduled health care appointment. Allowing for these different views is essential in maintaining an effective nurse-patient relationship. Scolding or acting annoyed at patients for being late undermines their confidence and may result in further missed appointments or indifference to health care suggestions.

Biologic Variations

Based on the idea that everyone is influenced by cultural variations, and the number of variations is increasing everywhere with the large number of immigrants moving from one country to another, nurses must understand cultural variation as a basis for even minimally safe and effective care. Often, biologic variations are grouped under the heading of culture; some aspects of biologic variation, in fact, affect and are affected by cultural beliefs and behaviors. Genetics and environment, and their interaction, cause humans to vary biologically. Gene variations cause obvious differences like eye color and genetic diseases, such as trisomy 21. Genes are identified increasingly as playing a role in most diseases, even if only to increase or decrease a person's susceptibility to infectious or chronic diseases. Environment has also been proved to cause disease, but modern Western thought on disease causation leans toward a mingling of genetics and environment. If, for example, a person has lungs that are genetically "hardy," then exposure to smoking may not cause lung cancer or chronic lung disease. Physical variations (resulting from genetics or cultural behaviors) are included directly in the normal and abnormal findings in the physical assessment chapters throughout the book. Integrating the information helps the nurse to attend to the possible variations during all assessments rather than having to seek the information elsewhere if the client appears to be from a different culture. One limitation of this approach has to be acknowledged. Because characteristics vary along a continuum with many possible points of reference, it would be cumbersome to include every possible variation as the point from which a characteristic varies. Acknowledging that this is an imperfect approach, the authors have used the U.S. population majority group as the point from which variation is assessed. As U.S. population demographics change, the baseline point will have to change in future texts. In his model of cultural competence, Purnell (2013) includes a category called biocultural ecology. This category refers to the client's physical, biologic, and physiologic variations, such as variations in drug metabolism, disease, and health conditions. Obviously, because an assessment text cannot discuss all of the topics in biologic variation, only a sampling is included here. The variations selected for inclusion are among those most often seen or most likely to be interpreted incorrectly as normal or abnormal.

Factors Affecting Disease, Illness, Health State

Biomedical variations Nutrition/dietary habits Family roles and organization, patterns Workforce issues High-risk behaviors Pregnancy and childbirth practices Death rituals Religious and spiritual beliefs and practices Health care practices Health care practitioners Environment Family content is addressed in Chapter 33, and religious and spiritual content in Chapter 12. Knowing what issues the culturally different client may have at work and what high-risk behaviors are common to the cultural group, as well as the environment from which the client comes, can give clues to current health status. Assessing health care beliefs is as important as understanding culturally based health care practices. Nutrition and biomedical variations are discussed later in this chapter. As this is an assessment text, only the most common cultural and biologic variations are covered here. More comprehensive content is available in transcultural nursing and cultural anthropology texts.

Gerontologic Considerations

Both the number and proportion of Americans 65 years of age and older have grown substantially in the past century. In 2017, an estimated 47.8 million older adults resided in the United States; this number continues to climb, with the greatest growth in the Hispanic population (U.S. Census Bureau, 2017). The health care needs of older adults are complex and demand significant investments, both professional and financial (see Chapter 8 for further discussion). Many older adults suffer from multiple chronic conditions that are exacerbated by acute episodes. In particular, older women are frequently underdiagnosed and undertreated. According to the United Nations' (2017) report on world population aging, globally, the number of people 80 years of age or older is projected to increase more than threefold between 2017 and 2050, rising from 137 to 425 million.

Cultural competence

By the middle of the 21st century, the non-Hispanic Caucasian population is projected to proportionally decrease so that it will no longer comprise the majority population, and other ethnic and racial populations (i.e., minority populations as compared to non-Hispanic Caucasians) will collectively comprise the majority of all Americans. This projected phenomenon is called the majority-minority crossover (Colby & Ortman, 2015). According to the 2017 National Nursing Workforce Survey, more than 80% of all nurses are Caucasian (Smiley, Lauer, Bienemy, et al., 2018). Progress toward increasing the percentage of culturally diverse nurses has been significantly slower than the increasing percentage of ethnic minorities in the United States. Educational institutions must prepare nurses to deliver culturally competent care and must work to increase the number of ethnic minority providers in the nursing workforce. Culturally competent care is defined as effective, individualized care that demonstrates respect for the dignity, personal rights, preferences, beliefs, and practices of the person receiving care while acknowledging the biases of the caregiver and preventing these biases from interfering with the care provided. Nurse educators are exploring creative ways to promote cultural competence and humanistic care in nursing students, including offering multicultural health studies in their curricula. Simulation methods and role-playing could be effective methods to practice person-centered culturally competent care (Fioravanti et al., 2018). Cultural diversity remains an important issue in health care today. Nurses are expected to provide culturally competent care for patients. To do so, nurses must work effectively with the increasing number of patients, nurses, and health care team members whose ancestry reflects the multicultural complexion of contemporary society.

Nervous System

Cerebrovascular disease (CVD) has neurologic effects, but the cause is vascular. The same patterns of ethnic variation that occur in CVD (see Chapters 21 and 22) occur with stroke. In the United States, the states of the "stroke belt" (North Carolina, South Carolina, Georgia, Alabama, Mississippi, Louisiana, Arkansas, Tennessee; the states with highest incidence being called the "stroke buckle," which are North and South Carolina and Georgia) have greater occurrence of stroke and vascular disease, which may be due to high percentages of older adult and African American dietary factors (National Institute of Neurological Disorders and Stroke [NINDS], 2011). Children born and living in these states during childhood show greater risk for stroke in adulthood (Glymour et al., 2007). Occurrence of dementia, including Alzheimer disease, is rising rapidly, especially in developing countries where the number of elderly is increasing (China, India, other South Asian and Pacific Island countries (Alzheimer's Disease International, 2007). Over 50% of dementia cases in Caucasians are Alzheimer's, but the rate in developing countries and in other ethnic groups has not been well studied. However, a research report from the University of Cambridge (2014) suggests that better hygiene (less exposure to bacteria, viruses, and other microorganisms) in wealthy nations may increase Alzheimer's risk.

cognitive level

Cognitive level is a key factor affecting a child's pain perception and response and usually goes hand in hand with the child's age. Cognitive level typically increases with age, thereby influencing the child's understanding of the pain and its impact and his or her choices for coping strategies. In addition, as the child's cognitive level increases, his or her ability to communicate information about pain increases. However, this increased understanding and ability to communicate with advancing age may not apply to the child experiencing developmental delays. For example, a developmentally delayed school-age child or adolescent may have the cognitive level of a toddler or preschooler. Health care providers need to be cognizant of this difference when caring for the child in pain.

Assessing for Patients' Cultural Beliefs

Communication •Do you like communicating with friends, family, and acquaintances? •When asked a question, do you usually respond? •If you have something important to discuss with your family, how would you approach them? Space •When you talk with family members, how close do you stand? •When you talk with acquaintances, how close do you stand? •If a stranger touches you, how do you react or feel? •If a loved one touches you, how do you react or feel? •Are you comfortable with the distance between us now? Social Organization •What are some activities that you enjoy? •What are your hobbies, or what do you do when you have free time? •Do you believe in a Supreme Being? •How do you worship that Supreme Being? •What is your role in your family/unit system? Time •Do you wear a timepiece daily? •If a nurse tells you that you will receive a medication "in about a half hour," how much time will you allow before calling the nurse? Environmental Control •Is it acceptable for you to have visitors drop in unexpectedly? •Do you use home remedies? Which home remedies worked? Will you use them in the future? •What is your definition of "good health"? •What is your definition of illness or "poor health"? Biologic Variations •What diseases or illnesses are common in your family? •Who usually helps you to cope during a difficult time? •What foods do you and your family like to eat? What foods are family favorites or are considered traditional? Nursing Process Utilization •Note whether the patient has become culturally assimilated or observes own cultural practices. •Incorporate data into the plan of nursing care.

Pregnancy and Childbearing

Cultural variation concerning pregnancy and childbearing practices includes "sanctioned and unsanctioned fertility practices; views toward pregnancy; and prescriptive, restrictive, and taboo practices related to pregnancy, birthing, and the postpartum period" (Purnell, 2013, p. 32). It may be surprising to some nurses that accepted practices for getting pregnant, delivery, and childcare vary across cultures. Beliefs about conception, pregnancy, and childbearing are passed from generation to generation (an example of the transmission of culture). Fertility control varies by culture and religion. Use of sterilization is accepted by some, rejected by others, and forcibly used in other cultures. Rituals to restrict sexuality are used in some cultures, including female circumcision (removal of the clitoris or the vulva, sewing together of the surrounding skin, leaving only a small hole for urination and menstruation). Stoning or other forms of killing women who become pregnant out of wedlock is common in some Islamic cultures. U.S. culture has pregnancy taboos just as others do. Pregnant women are expected to avoid environments with very loud noises, avoid smoking and alcohol, avoid high caffeine and drug intake, and be cautious about taking prescription and over-the-counter medications. Other cultures have pregnancy taboos such as having the mother avoid reaching over her head to prevent the umbilical cord from going around the baby's neck, not buying baby clothes before birth (Navajo), and not permitting the father to see the mother or baby until the baby is cleaned (Belize and Panama)

CULTURAL INFLUENCES ON GROWTH AND DEVELOPMENT school age

Culture influences habits, beliefs, language, and values. School-age children thrive on learning the music, language, traditions, holidays, games, values, gender roles, and other aspects of culture. Nurses must be aware of the effects on children of various groups' family structures and traditional values. The school-age child's cultural and ethnic backgrounds must be considered when assessing growth and development, including differences in growth in children of different racial and cultural backgrounds. Cultural implications must be considered for all children and families in order to provide appropriate care.

Culture-Based Treatments

Culture-based treatments are often misinterpreted in Western health care settings, as they frequently produce marks on the skin that are interpreted as evidence of abuse. Assuming abuse can create a very bad nurse-client interaction and can cause the culturally different client to reject Western-style health care in the future. Some of the more common Asian treatments are cupping, coining, and moxibustion. Cupping, often used to treat back pain, involves placing heated glass jars on the skin. Cooling causes suction that leaves redness and bruising. Coining involves rubbing ointment into the skin with a spoon or coin. It leaves bruises or red marks, but does not cause pain (Fig. 11-6). It is used for "wind illness" (a fear of being cold or of wind, which causes loss of yang), fever, and stress-related illnesses such as headache. Moxibustion is the attachment of smoldering herbs to the end of acupuncture needles or the placement of the herbs on the skin; this causes scars that look like cigarette burns. It is used to strengthen one's blood and the flow of energy, and generally to maintain good health. The American Cancer Society (2008) has noted that in Native American culture, medicine is more about healing the person than curing a disease. There is a spiritual element at the base of their healing practices. One of the most common forms of Native American healing practices involves the use of herbal remedies. These herbal remedies include teas, tinctures, and salves. A common Native American remedy for pain uses bark from a willow tree, which contains acetylsalicylic acid, also known as aspirin (Fig. 11-7). Other treatments are related to different beliefs about what causes disease. In many cultures an imbalance in hot/cold is believed to cause disease, so treatment would be to take foods, drinks, or medication of the opposite type (hot for a cold condition and cold for a hot condition). What is thought to be hot or cold has no relation to temperature. Cancer, headache, and pneumonia are described as cold, whereas diabetes mellitus, hypertension, and sore throat or infection are hot. One example of a Western versus Latino treatment belief difference is pregnancy. Pregnancy is a hot condition; iron-containing foods are also hot, thus a pregnant female should not eat iron-containing foods. In Asian societies, hot/cold is also associated with the body's energy of yin/yang, which must remain in balance for health. The yin/yang balance is maintained through diet, lifestyle, acupuncture, and herbs (Fig. 11-8). Some standard Western treatments are unacceptable in other cultures. Counseling or psychiatric treatments are resisted by some Asians and many other cultures because psychological or psychiatric illness is considered shameful.

Culture-Bound Syndromes

Culture-bound syndromes are conditions that are perceived to exist in various cultures and occur as a combination of psychiatric or psychological and physical symptoms. There is much debate over whether these syndromes are folk illnesses with behavior changes, local variations of Western psychiatric disorders, or whether they are not syndromes at all but locally accepted ways of explaining negative events in life. Because clients perceive the syndromes to be conditions with specific symptoms, it is necessary to be familiar with them. It is important to acknowledge the client's belief that the symptoms form a disorder even if Western medicine calls it something else or does not see it as a specific disease. Table 11-2 provides a description of some of the more common culture-bound syndromes. Many of the culture-bound syndromes are based on different beliefs about what causes disease, as described earlier. The symptoms related to the conditions are often specific to a particular culture.

CULTURAL CONSIDERATIONS FOR THE POSTPARTUM PERIOD

Cultures vary in their postpartum beliefs, practices, and customs. Nurses practice in an increasingly multicultural society. Therefore, they must be open, respectful, nonjudgmental, and willing to learn about ethnically diverse populations. Although childbirth and the postpartum period are unique experiences for each individual woman, how the woman perceives and makes meaning of them is culturally defined. Somali women are highly regarded in Somali society for their roles as mothers. Postpartum women stay at home and refrain from sexual activity for 40 days. At the end of 40 days, there is a celebration and this typically marks the first time the mother and infant have left the home since childbirth. The majority of Somali and Arab women breastfeed and do so for extended periods of time (Giger, 2019). Nurses need to offer early breastfeeding instruction to support their efforts while still in the hospital setting before discharge.

Biochemical Variation and Differential Disease Susceptibility

Drug metabolism differences, lactose intolerance, and malaria-related conditions—such as sickle cell disease, thalassemia, glucose-6-phosphate dehydrogenase (G6PD) deficiency, and Duffy blood group—are considered biochemical variations. The malaria-related conditions would obviously occur in populations living in or originating from mosquito-infested locales such as the Mediterranean and Africa. Lactose intolerance is another variation. Most of the world's population is lactose intolerant. The ability to digest lactose after childhood relates to a mutation that occurs mainly in those of North and Central European ancestry and in some Middle Eastern populations, with a high prevalence of lactose intolerance in South America, Africa, and the highest of all in some populations of Asia (ProCon.org, 2010, which provides results of many studies; Vesa et al., 2000). There have been many studies on ethnic, racial, or biologic variations in drug metabolism. Purnell (2013) has provided extensive reviews of ethnic-racial group differences in drug metabolism. As Purnell noted, among other variations, Chinese are more sensitive to cardiovascular effects of some drugs and have increased absorption of antipsychotics, some narcotics, and antihypertensives. Eskimos, Native Americans, and Hispanics have increased risks for peripheral neuropathy with isoniazid. African Americans have a better response to diuretics than do Caucasians. Many conditions can alter drug metabolism as well; for instance, smoking accelerates it, malnutrition affects it, stress affects it, and low-fat diets decrease absorption of some drugs. Cultural beliefs about taking medication affect their use. Ethnopharmacology is an entire area of study with its own society (International Society of Ethnopharmacology) and journal (Journal of Ethnopharmacology) dedicated to exchanging information about peoples' "use of plants, fungi, animals, microorganisms and minerals and their biologic and pharmacologic effects based on the principles established through international conventions" (Verpoorte, 2016, p. 1). These brief examples of ethnic variation of diseases or susceptibility to disorders show that health status and health assessment are greatly influenced by biologic variations. Many of the chapters in this text include physical characteristics to be assessed that have normal variations or that vary in the way abnormalities are expressed. These variations are inserted into the physical assessment discussions. Also, many of the chapters include risk factor discussions addressing common illnesses associated with the content of the chapter.

Immigration

Employment, economic and educational opportunities, expanded human rights, and other types of freedoms and opportunities encourage many foreigners to move to the United States. There are a growing number of immigrants with approximately one in four children in the United States being immigrants or members of an immigrant family (Child Trends Databank, 2018a). More than half of all immigrant children are of Hispanic origin (Child Trends Databank, 2018). This includes both children born outside the United States or with at least one foreign-born parent. Some communities welcome the new members, but others do not. Partly due to fears of terrorism, the United States is evaluating, enforcing, and changing many of its immigration laws. Immigration can affect the health, educational, and social services provided in the United States. It also presents issues related to access to care and the types of care that need to be offered. Immigration imposes stresses on women, children, and families, including the following: Unique health issues such as communicable and noncommunicable diseases specific to their country or origin, oral health issues, altered nutrition, and growth Depression, grief, or anxiety due to migration and adoption of a new culture Separation from support systems Inadequate language skills Differences in social, professional, and economic status between the country of origin and the United States Traumatic events such as war that may have occurred in their homeland (AAP, 2019d; Linton et al., 2019) Inability to speak English can hinder an immigrant's educational attainment, economic opportunities, and ability to join the mainstream of society. One third of children living in the United States speak a language other than English at home (Linton et al., 2019). Immigrant parents who do not speak English may have trouble accessing health care and health insurance, enrolling their children in school or becoming involved in school activities, and accessing work or better-paying jobs. Immigrant families also may arrive in the United States with significant health problems. They may present with diseases that are more common in their country of origin but rarely seen in the United States, such as malaria. The health status of immigrant children may be compromised due to the lack of at-birth and early childhood screenings, which may manifest with problems such as inborn errors of metabolism, lack of preventive care, no immunizations, and no dental care. Due to financial, language, cultural, and other types of barriers that immigrant families sometimes face, they may not receive the necessary preventive care or receive care for minor conditions until they become more serious. Stresses experienced by immigrant children and their families, such as those associated with relocation, separation, and traumatic events, also can have a negative impact on their psychological health.

Promoting a Healthy Sexual Identity

Encourage parents and teens to have discussions about sexuality. In addition, nurses should ensure that adolescents have the knowledge, skills, and opportunities that enable them to make responsible decisions regarding sexual behaviors and sexual orientation. Education for the adolescent should include a discussion about media influences and the use of sexuality to promote products. This discussion should make the adolescent aware of the motives of the media and the need to be an individual and not be influenced by television, magazines, and other forms of advertisement. Encourage parents to be aware of who their adolescents are dating and where they go on their dates.

The following may affect interactions between clients and their health care providers:

Ethnicity (of both client and health care provider) Generational status (of both client and health care provider) Educational level Religion Previous health care experiences Occupation and income level Beliefs about time and space Communication needs/preferences Ask clients about their cultural and ethnic backgrounds. How close to the primary culture does the person feel? To the ethnic group? To country of origin? What age was the client at immigration (if applicable)? How frequently does the client travel to and from the country of origin? If the person seeking care is from a cultural group but is well acculturated to Western values, assuming that he or she follows practices of the cultural group is stereotyping and will lead to conflict. Generational status may be important. In some cultures, it still may be the practice that older family members have more say in health care and treatment than clients themselves, even if the client is an adult (this is especially true for females). Autonomy is assumed to be a right of all health care consumers in the United States, meaning that individuals have the right to know about diagnosis and treatment plans and to make decisions for themselves. However, autonomy is not an accepted value in many societies. In paternalistic or patriarchal societies, the father or the family is expected to be informed of diagnoses and to make decisions about treatment. In many societies, women are not decision makers. Do not assume that the client expects autonomy; clarify expectations with the client and family. Client autonomy is a legal issue in U.S. health care; thus, you will need to clearly explain this concept to the family and client. The information should be presented in such a way as to avoid a hostile response or the withdrawal of the client from Western health care. Respect is highly valued in many cultures and older age often conveys an expectation of respect. Older clients may not respect younger providers. Younger clients may fear disclosing health details to older providers. Older clients may feel uncomfortable or fail to disclose to providers of a different gender. Education level plays an important role in health care, and it is essential to assess language proficiency. Does the client have the ability to understand spoken and written English? Can the client speak or write English? Will the individual accept an interpreter? If so, will an interpreter of a different age or gender be acceptable? For instance, some cultures do not allow a young person or a person of different gender to hear personal details. Religious rules and norms may affect who can assess, who can treat, and what treatments are acceptable, among many other aspects of health care. Previous experience with the primary health care system may affect provider interactions. Were past experiences positive or negative? Occupation and income level may affect ability to pay and follow prescribed care. Ideas about time, space, and communication are especially important and necessitate specific discussion.

Body Surface Variation

Examples of surface variations can be seen in the following secretions: variation in apocrine and eccrine sweat secretions and the apocrine secretion of earwax. Sebaceous gland activity and secretion composition do not show significant variation. Eccrine glands, distributed over the entire body, show no variation in number or distribution but do vary in activity based on environmental and individual adaptations (not by race; Taylor, 2006). People born in the tropics have more functioning glands than those born in other areas and those who move to the tropics later in life; persons acclimatized to hot environments have lower chloride excretion in their sweat. Apocrine glands, opening into the hair follicles in the axilla, groin, and pubic regions; around the anus, umbilicus, and breast areola; and in the external auditory canal; vary significantly in the number of functioning glands. Asians and Native Americans have fewer functioning apocrine glands than do most Caucasians and African Americans (Preti & Leyden, 2010). The amount of sweating and body odor is directly related to the function of apocrine glands, and has a genetic base. The odor is probably related to the decomposition of lipids in the secretions. Prepubescent children, Asians, and Native Americans have no or limited underarm sweat and body odor. Earwax, produced by the apocrine glands in the external ear, varies between dry and wet wax based on genetics. Europeans and Africans tend to have wet earwax and East Asians tend to have dry earwax (Nakano et al., 2009). The same genetic variation leads to women with dry earwax having a lower incidence of breast cancer, seen especially in East Asian women. Interestingly, the low number of Japanese women with wet earwax have been shown to have a higher risk of breast cancer than other Japanese women, apparent further evidence for the association between wet earwax and breast cancer risk (Ota et al., 2010). However, Beesley et al. (2011) found no association between a genetic variation for wet earwax and breast cancer risk in Caucasian women.

ASSESSING TEACHING AND LEARNING NEEDS

Excellent nursing care begins with a thorough assessment of the client. In the same way, client and family education begins with a learning needs assessment that includes the clients and family's learning needs, learning styles and preferences, and potential barriers to learning. Based on the results of the assessment, an individualized plan can be developed to reduce the time and effort required for teaching while maximizing learning for the client and family. Although actual nursing care in pediatrics is given to the child, the educational process is targeted at both the child, when developmentally appropriate, and the adult members of the family. Therefore, it is advisable to conduct a learning needs assessment on both the adult caregivers and the child, when appropriate. Box 2.2 describes the components of a learning needs assessment. This is also a good time to establish rapport with the family, demonstrating your interest in them and your confidence in their ability to learn. Share the assessment with all members of the interdisciplinary team so that the entire team can support the client's and family's learning. Although assessment generally takes place during the first or second meeting with the client and family, it should also occur with each encounter to check for any changes that may occur.

Factors associated with potential nutritional deficits

Factor Possible Consequences Dental and oral problems (missing teeth, ill-fitting dentures, impaired swallowing or chewing) Inadequate intake of high-fiber foods Nothing by mouth (NPO) for diagnostic testing Inadequate caloric and protein intake; dehydration Prolonged use of glucose and saline intravenous fluids Inadequate caloric and protein intake Nausea and vomiting Inadequate caloric and protein intake; loss of fluid, electrolytes, and minerals Diarrhea Loss of fluid, electrolytes, and minerals; malabsorption of nutrients Stress of illness, surgery, and/or hospitalization Increased protein and caloric requirement; increased catabolism Wound drainage Loss of protein, fluid, electrolytes, and minerals Pain Loss of appetite; inability to shop, cook, eat Fever Increased caloric and fluid requirement; increased catabolism Gastrointestinal intubation Loss of protein, fluid, and minerals Tube feedings Inadequate amounts; variation of nutrients in each formula Gastrointestinal disease Inadequate intake and malabsorption of nutrients Alcoholism Inadequate intake of nutrients; increased consumption of calories without other nutrients; vitamin deficiencies Depression Loss of appetite; inability to shop, cook, eat Eating disorders (anorexia, bulimia) Inadequate caloric and protein intake; loss of fluid, electrolytes, and minerals Medications Inadequate intake due to medication side effects, such as dry mouth, loss of appetite, decreased taste perception, difficulty swallowing, nausea and vomiting, malabsorption of nutrients Restricted ambulation or disability Limited ability to shop, cook, or help self to food, liquids, other nutrients

Physical Effects of Hormone Treatment for Gender Reassignment

Feminizing Hormones (Male to Female) Masculinizing Hormones (Female to Male) Reduction in growth and thinning of body hair Growth of facial and body hair; scalp hair loss Breast formation Decrease in glandular activity of breasts Softening of skin and decreased oiliness Skin oiliness and acne Increase in body fat and decrease in muscle mass Decrease in subcutaneous fat, increase in abdominal fat, and increase in muscle mass Testicular and prostate volume atrophy Clitoral enlargement and vaginal atrophy Decreased sperm production Cessation of menses

Abdomen

Gallbladder disease and gallbladder cancer vary by ethnic group in the United States. Native Americans and Mexican Americans have higher rates of disease and cancer in this organ (ACS, 2014). Stomach cancer has an association with the prevalence of Helicobacter pylori (which also causes ulcers). The highest incidence of stomach cancer is in Asia, Latin America, and the Caribbean, and the lowest incidence in North America and Africa. Countries with the highest incidence are Korea, Mongolia, and Japan (Ferlay et al., 2012; Lyons France, 2014). Ashkenazi Jews have been found to have the highest lifetime risk for developing colorectal cancer (ACS, 2016). Cancer in general has a different pattern for Asian Americans than for those remaining in Asia. The rate of cancer is low for Asian Americans but the death rate from cancer is higher. There is a variable pattern of specific cancers across Asian groups

Factors in cultural assessment

Giger (2016) identifies a model for assessing clients using six cultural factors: communication, physical distance or p. 121p. 122 space, social organization, time orientation, environmental control, and biologic variations

Cultural Health Practices

Health practices are often the result of health beliefs derived from a person's culture. For example, do the child and family view health and illness as the result of natural forces, supernatural forces, or the imbalance of forces? Most cultures have remedies that people may use or consider before they seek professional health care. People from some cultures may go to folk healers who they believe can cure certain illnesses. For example, the curandero (male) or the curandera (female) of the Mexican American community is believed to have healing powers as a gift from God. Asian Americans may consult a practitioner who specializes in traditional Asian therapies such as acupuncture, acupressure, and moxibustion. These folk healers are often very powerful in their community, speak the language, and are very familiar with the culture's spiritual or religious aspects. If the folk remedies or practices of the folk healers are compatible with the health regimen and support appropriate health practices, these practices and beliefs do no harm; in fact, they may even benefit the child and family. However, use of a folk healer can lead to a delay in beneficial treatment or create other problems. Some traditional health practices may be misinterpreted as being harmful, and some actually can cause harm. For example, the Vietnamese practice of coining, which involves rubbing the edge of a coin on an oiled symptomatic body area to rid the body of disease, may be misinterpreted as a sign of physical abuse (Marion et al., 2018). This practice also can lead to burns, bruising, or welt-like lesions on the child's skin if it is done frequently. Azarcon and greta, powders containing high amounts of lead, are used as a folk remedy in Mexico to treat empacho, digestive problems such as diarrhea, and indigestion; and in some cases have resulted in lead toxicity

Health Disparities in the Gay, Lesbian, Bisexual, and Transgender (LGBT) Population

Healthy People 2020 (2018b) identified significant LGBT health disparities and seeks much-needed collaboration from health care professionals and policy makers to address them. Among its findings are the following: LGBT youth are two to three times more likely to attempt suicide. LGBT youth are more likely to be homeless. Lesbians are less likely to get preventive services for cancer. Gay men are at higher risk of HIV and other sexually transmitted infections, especially among communities of color. Lesbians and bisexual females are more likely to be overweight or obese. Transgender people have a high prevalence of HIV and sexually transmitted infections, victimization, mental health issues, and suicide: They are less likely to have health insurance than heterosexual, lesbian, gay, or bisexual people. Older LGBT people, referred to as elders by the LGBT community and trans elders in the transgender community, face additional barriers to health due to isolation and a lack of social services and culturally competent providers.a LGBT populations have the highest rates of tobacco, alcohol, and other drug use. These health issues are partly thought to be the effects of chronic stress resulting from stigmatization.b

Ethics of sex

Healthy sexuality depends on freedom from guilt and anxiety. What one person believes is wrong may be perfectly natural and correct to another. Some people may feel that certain forms of sexual expression are bizarre, and the people who participate in them are perverted. If the sexual expression is performed by consenting adults, is not harmful to them, and is practiced in privacy, it should not be considered a deviant behavior. People should personally decide which aspects of sexual expression are comfortable for them. Frequently, all a person needs to alleviate guilt, and consequently enhance sexual satisfaction, is permission from a health care professional to engage in a different form of expression.

Hair removal

Hormone treatment does not typically fully eliminate unwanted hair, and thus people who are transgender may seek additional gender-affirming medical procedures. Transgender women typically seek hair removal on the face, neck, and in the genital area as preoperative preparation for vaginoplasty. Transgender men typically seek hair removal on the forearm and thigh when needing graft sites for phalloplasty. Like hormone treatment, hair removal is associated with both decreased dysphoria and increased well-being among people who are transgender (Bradford, 2019). Although numerous treatments exist to help manage unwanted hair, there are two primary medical procedures used for long-term treatment: laser hair removal and electrolysis (Reeves, Deutsch, & Stark, 2016). Laser hair removal is the leading therapy option for long-term results and works on the principle of selective photothermolysis, whereby photons destroy the hair follicle while sparing the surrounding tissue (Thomas & Houreld, 2019). The main risks of this procedure are overheating resulting in redness, blisters, and burns. Treatments should be avoided when photosensitizing medications are being used, such as acne medications (e.g., isotretinoin, minocycline, doxycycline), antibiotics (e.g., tetracyclines, sulfonamides, quinolones), and spironolactone. Nurses should review a patient's medication list and identify those that are photosensitive. Electrolysis involves the use of an electric current that destroys the root of individual hair follicles. This treatment is more time consuming and more painful than laser hair removal. The main risks of electrolysis are redness and pigment changes. To help manage the pain during laser hair removal and electrolysis, topical anesthetics (lidocaine-containing products) and acetaminophen are used

Sexuality

Human sexuality is the way people experience and express themselves sexually. This involves biological, physical, emotional, or social feelings. Sexual orientation, which is a component of sexuality, is different than gender (see discussion below). Sexual orientation is an umbrella term that refers to romantic, emotional, or sexual attraction to persons of the opposite gender, the same gender, or to more than one gender. There are many terms that people use to describe their sexual orientation; however, the most commonly used terms are heterosexual or straight, gay or lesbian, bisexual, and queer. People who are attracted to a different gender, such as women who are attracted to men, typically identify as heterosexual or straight. People who are attracted to the same gender, such as men attracted to men, often identify as gay. Gay women may prefer the term lesbian. People who are attracted to both male and female genders usually identify as bisexual. Although the term queer was historically used as a word of insult, many people now choose to use it to identify their sexual orientation. People who are queer typically experience attractions to numerous genders (male, female, transgender, intersex, etc.). A person who does not want to use labels, such as gay, lesbian, or bisexual, may also use the term queer to identify as a nonheterosexual. People who are exploring or are unsure of their sexual orientation may refer to themselves as questioning. Questioning one's own sexuality can be difficult and confusing and can take years to understand. This term can also apply to people who are concerned about applying a social label (e.g., gay, lesbian, bisexual, queer) to themselves and may prefer to use this term.

Barriers to Cultural Competemility

Illness is culturally shaped in the sense that how we perceive, experience, and cope with disease is based upon our explanations of sickness. Awareness of how this might be of influence—instead of mere knowledge about the cultural practices or beliefs of specific ethnic groups—and an appreciation of this factor helps nurses deal effectively with cultural issues (Christensen, 2019). When a health care provider lacks knowledge of a client's cultural practices and beliefs or when the provider's beliefs differ from those of the client, the provider may be unprepared to respond when the client makes unexpected health care decisions. System-related barriers can occur if agencies, that have not been designed for cultural diversity, want all clients to conform to the established rules and regulations and attempt to fit everyone into the same mold. Cultural competemility does not mean replacing one's own cultural identity with another, ignoring the variability within cultural groups, or even appreciating the cultures being served. Instead, nurses skilled at cultural competemility show a respect for difference, an eagerness to learn, and a willingness to accept multiple views of the world. Much of the process of developing cultural competemility involves a reexamination of our values and the influence of these values on our beliefs, which affect our attitudes and actions. At the core of both client centeredness and cultural competemility is the importance of seeing the client as a unique person. It involves letting go of assumptions about an individual based on their culture and creating space for learning who they are as a person—in other words, experience their own ethos (Shepherd et al., 2019). It is important for all nurses to incorporate the client's traditional healing and health practices with conventional medicine by asking such questions as: Do you have treatment preferences you would like me to include in your care plan? Some clients may prefer certain foods or drinks when they are ill. In addition, during fasting and religious seasons, diets may be different and need to be considered during the process of determining the appropriate course of treatment. Some may have a different idea of what caused the illness. Spirituality, culture, and experience may have a significant role in the client's understanding and treatment of the illness.

Hormone Therapy

In addition to alleviating gender dysphoria, the goal of hormone gender-affirming therapy is the acquisition of the secondary sex characteristics of the other gender, to the fullest extent possible (Gooren, 2016). To achieve the secondary sex characteristics of the opposite gender, sex steroids/hormones are needed. There is no known difference in sensitivity to the action of sex hormones on the basis of genetics or gonadal/sex status (Gooren, 2016), meaning that a person can develop secondary sex characteristics of the opposite gender by taking sex hormones. However, certain effects of sex hormones cannot be reversed. For example, in people who are transgender women (male to female), the previous effects of androgens on the skeleton (average greater height; size and shape of hands, feet, and jaw; and pelvic structure) cannot be reversed by hormones (Gooren, 2016) (Table 54-2). For patients who are transgender women, estrogen is prescribed to produce the desired physical changes. The prescribed dose of estrogen is individualized and depends on many different factors, such as the patient's goals, risk/benefit ratio, presence of other medical conditions, presence or absence of gonads, and social and economic issues (WPATH, 2012). Estrogen treatment should produce changes in body hair, breast development, skin, body fat composition, muscle mass, testes, and prostate. In addition to estrogen, androgen-reducing medications to reduce testosterone levels are also often prescribed, which diminish masculine characteristics and minimize the dosage of estrogen needed to suppress testosterone. Common androgen-reducing medications include spironolactone, cyproterone acetate, GnRH agonists (e.g., goserelin, buserelin, triptorelin), and 5-alpha reductase inhibitors (e.g., finasteride, dutasteride) (WPATH, 2012). Progestogen does not add to the feminization process and is typically not recommended due to the higher incidence of breast cancer and cardiovascular disease (Gooren, 2016). See Table 54-3 for commonly prescribed medications. In people who are transgender men (female to male), testosterone is prescribed to produce the desired physical changes. Like estrogen, the prescribed dose of testosterone is individualized and depends on many different factors. Testosterone treatment should produce changes in scalp hair, skin oiliness, facial and body hair, voice, body fat composition, muscle mass, menses, clitoris, and vagina As with any medical treatment, hormones carry risks to the person. The likelihood of a serious adverse event is dependent on numerous factors, such as dose, route of administration (e.g., oral vs. transdermal vs. intramuscular), and the patient's characteristics (e.g., age, comorbidities, health behaviors). People who take estrogen are at increased risk of venous thromboembolism (VTE), gallstones, elevated liver enzymes, weight gain, and hypertriglyceridemia. People who take testosterone are at increased risk for polycythemia, weight gain, acne, androgenic alopecia (male-patterned balding), and sleep apnea. In addition, both estrogen and testosterone can increase the risk of the person developing type 2 diabetes when they have additional risk factors, such as older age (WPATH, 2012).

CULTURAL IMPACT ON ASSESSMENT OF LEARNING NEEDS

In addition to determining the language spoken in the home and use of eye and physical contact, investigate the following during the assessment: Who is the person caring for the child at home? Who is the authority figure in the family? What is the social support structure? Are there any special dietary needs and concerns? Are any traditional health practices used (e.g., healers, shamans, talismans, folk remedies, and herbs)? Are any special clothes or other items used to help maintain health? What religious beliefs, ceremonies, and spiritual practices are important? Learning needs can then be negotiated with the family and met based on the assessment. Issues encountered when teaching immigrant or refugee families might include confusion regarding the use of the English versus the metric scale; preparing formulas and medicines using a "handful" or "pinch" of ingredients rather than specific measurements such as a measuring cup or syringe; access to refrigeration for liquid antibiotics; and breastfeeding practices.

Geographical and Ethnic Disease Variation

In general, chronic diseases predominate in developed countries and infectious diseases predominate in third-world countries. However, there is some genetic and ethnic variation in addition to the chronic versus infection pattern. Often the studies in developing countries and on immigrants from these countries to the United States are limited. Patterns are known, however, and are often based on body size, lifestyle, and genetics. For instance, vascular diseases tend to be higher in African Americans and populations with larger body size and lifestyle habits such as smoking. Osteoporosis is more prevalent in small-framed people such as Asians (National Institutes of Health Osteoporosis and Related Bone Diseases-National Resource Center [NIH ORBD-NRC], 2015a). Knowing that some groups will be more prone to a disease or condition can help the nurse to more carefully assess each client. Following are examples of geographic or ethnic disease variations for the physical systems.

Heart and Neck Vessels

In the United States, heart disease causes more deaths than other conditions among all ethnic groups. However, risks vary among the groups. Heart disease and all cardiovascular diseases are higher in the southern states of the United States, known as the "Stroke Belt" (CDC, 2015a). The Harvard Health Letter (2015) described rates of hypertension, diabetes, and heart disease variations among ethnic groups, concluding that many intertwined factors likely contribute to the higher heart disease rates seen among some groups. Findings include that nearly half of all African American adults have some form of cardiovascular disease, compared with about one third of all Caucasian adults, and even after adjustment for factors related to socioeconomic differences, disparities in rates of heart disease and its risk factors persist. A possible explanation suggested by some researchers is that people who lived in equatorial Africa developed a genetic predisposition to being salt-sensitive, which means their bodies retain more sodium. An interesting phenomenon is what has been called the "Hispanic paradox," in which those of Hispanic ethnicity have a higher prevalence of diabetes and obesity and higher death rates related to diabetes, chronic liver disease/cirrhosis, and environmental conditions conducive to disease compared with Caucasians, but have a lower overall cardiovascular disease and mortality rate by 2 years than Caucasians (CDC, 2015b).

Acne treatment

In transgender men, testosterone is the mainstay of masculinizing hormonal therapy. Although the exact mechanism in the pathogenesis of acne is not yet fully understood, testosterone increases the production of sebum (oily secretion) in sebaceous glands, leading to acne. Facial acne in transgender men who use testosterone peaks within the first 4 months of treatment; over 80% of testosterone-treated transgender men experience facial acne in the first year (Motosko, Zakhem, Pomeranz, et al., 2018). General guidelines for acne treatment can be followed for transgender men (Thiboutot, Dréno, Abanmi, et al., 2018); however, there are some specific considerations and risks. First, combining testosterone with some acne medications, especially minocycline, may lead to hepatotoxicity; thus, frequent monitoring of liver function tests is warranted. Second, some acne medications are teratogenic, such as minocycline, doxycycline, and isotretinoin. For transgender men who are still at risk of pregnancy (intact uterus and ovaries), careful sexual history and counseling should be performed before the initiation of any acne treatment. Third, some acne medications, especially isotretinoin, may delay wound healing and lead to keloid formation after surgery; thus, a discussion about surgical plans is needed before starting acne treatment

gerontologic considerations for LGBTQ

In understanding older adults who are LGBTQ, it is important to recognize their social, historical, and cultural experiences. The lived experience of older adults who are LGBTQ is vastly different than younger people who are LGBTQ. Older adults who are LGBTQ lived their younger years in stigmatizing and dangerous environments (Ducheny, Hardacker, Claybren, et al., 2019). They frequently experienced discrimination and abuse in multiple areas, including physical, mental, and verbal abuse (Witten & Eyler, 2016). For many decades, it was dangerous for people who were LGBTQ to "come out" (disclose their sexual orientation or gender identity) and extremely difficult to find affirming health care services. Before the 1960s, people who identified as transgender were often committed to psychiatric institutions or forced to live in seclusion. From 1960 through 1990, people who identified as transgender could access rigid and isolating treatment and were made to adhere to narrow requirements (Ducheny et al., 2019). Until 1973, homosexuality was a diagnosed psychiatric mental illness. Moreover, older people who are LGBTQ faced significant discrimination that was sanctioned by state and federal governments. This history has profoundly affected the way in which older adults who are LGBTQ view and access all facets of health care, including clinics, hospitals, and assisted living/nursing homes (Witten & Eyler, 2016). To care for and promote the health of older adults who are LGBTQ, nurses should be mindful and understanding of this background. Moreover, this amplifies the importance of nurses needing to always provide a safe and welcoming space for all patients that promotes human dignity. Older adults who have hidden their sexual orientation or gender identity for many years due to fears of discrimination will be more likely to disclose this information if the nurse uses language and questions that signals to the patient that they are accepting and safe.

Thorax and Lungs

Lung cancer is directly related to smoking and to the quantity of cigarettes smoked. The highest rates for lung cancer in the United States in a study from 2013 (CDC, 2016c) are among African American men, followed by Caucasian, American Indian/Alaska Native, Asian/Pacific Islander, and Hispanic men. And among women, Caucasian women had the highest rate of developing lung cancer, followed by African American, American Indian/Alaska Native, Asian/Pacific Islander, and Hispanic women. An interesting fact is that smoking rates do not correlate with lung cancer rates when examined by ethnicity. In a 2013 study (ALA, 2016), smoking rates were highest among American Indian/Alaska Native men, followed by Caucasian and African American men, and then Hispanic men and the lowest rates were for Asian men. The same ethnic pattern for smoking rates was found in women, with lower rates for each category than for men. The prevalence of nonmalignant lung diseases varies among different ethnic groups as well. Asthma prevalence has been found to be lowest among Asian and Hispanic adults, and highest among African American and Native American adults (Gorman & Chu, 2009). Gilkes et al. (2016) report the prevalence of chronic obstructive pulmonary disease (COPD) in the United Kingdom (where much research on COPD and ethnicity has taken place). These authors report the prevalence to be lower in Black and Asian people, with Blacks half as likely to have COPD as Caucasians when adjusting for lower smoking rates in Blacks.

Information Disclosure

Many aspects of care may be influenced by the diverse cultural perspectives held by health care providers, patients, families, or significant others. One example is the issue of communication and full disclosure. In general, nurses may argue that patients have the right to full disclosure concerning their disease and prognosis and may believe that advocacy means working to provide that disclosure. However, family members in some cultural backgrounds may believe that it is their responsibility to protect and spare the patient (their loved one) knowledge about a terminal illness. In some cultures, the head of the family group, older adult, or husband is expected to receive all information and make decisions. Patients may in fact not want to know about their condition and may expect their family members to "take the burden" of that knowledge and related decision making. Nurses should not decide that a family or patient is simply wrong or that a patient must know all of the details of their illness regardless of the patient's preference. Similar concerns may be noted when patients refuse pain medication or treatment because of cultural beliefs regarding pain or beliefs in divine intervention or faith healing. Determining the most appropriate and ethical approach to patient care requires an exploration of the cultural aspects of these situations. Self-examination and recognition of one's own cultural bias and worldview play a major part in helping the nurse resolve cultural and ethical conflicts. Nurses must promote open dialogue and work with patients, families, primary providers, and other health care providers to reach the culturally appropriate solution for the individual patient.

FACTORS AFFECTING SEXUALITY

Many factors influence a person's sexuality and contribute to personal feelings regarding sexuality. The brain, rather than the genitals, plays the most significant role in how people perceive themselves as sexual beings. Developmental, culture, religion, ethics, lifestyle

Fertility and Reproductive Health

Many people who are transgender will want to have biological children, but because hormone treatment limits fertility, patients should be educated about their options before starting hormone treatment or undergoing surgery to remove or alter their reproductive organs. Although the long-term effects of gender-affirming hormone therapy using testosterone or estrogen on fertility are not known, limited research suggests that testosterone and estrogen can affect the reproductive abilities of ovaries and testes, respectively (Cheng, Pastuszak, Myers, et al., 2019). There are cases of transgender women and men stopping hormone treatment and still having fertile oocytes or sperm; however, there are many cases to the contrary and thus patients who are transgender should be fully informed of the possible implications that hormones have on fertility and preservation options. In the postpuberty age group, transgender men should be educated about oocyte cryopreservation, embryo cryopreservation, and uterus preservation. Transgender women should be educated about sperm cryopreservation. In the prepuberty age group, trials are ongoing to determine the effectiveness of ovarian tissue cryopreservation and testicular tissue cryopreservation in transgender men and transgender women, respectively

Developmental variation

Maturity differences appear to be related to both genetics and environment. Caribbean Black, African Black, and Indian children are less likely to be experience delayed motor development than Caucasian children, but Pakistani and Bangladeshi children do not fit into this pattern (Kelly et al., 2006). African American infants and children tend to be ahead of other American groups in motor development (Martin & Fabes, 2009). However, these authors suggest that there is an interaction between biology and cultural factors that leads to this early development. Socioeconomic status has been found to have a direct relationship with fine motor skills

Male Contraceptives

Methods of contraception for men continue to be explored. The challenge of developing a reversible method of contraception for men is complicated because men are always producing sperm. Because of this continuous fertility, the opportunities for reversible intervention that are permitted by women's fertility cycles are not available in men. Effective contraceptive methods for men that do not permanently impair fertility have proven elusive, but research continues. Most research has focused on a hormonal approach to decrease spermatogenesis. The major problem is that interference with steroidogenesis may also interfere with the other actions of testosterone such as sexual function, bone and muscle growth, kidney function, and protein anabolism.

Sex lifestyle

Modern lifestyles greatly affect sexuality and its expression. Both men and women are exposed to stress, and many are under considerable strain to perform and function in the workplace as well as at home. Stressors may be external, such as job and financial demands, or internal, such as a person's competitive nature. Varied responsibilities may place a time constraint on communication between a couple, as well as on the energy level and motivation for sexual satisfaction. Although some couples view sexual activity as a release from the stressors of everyday life, most place nurturing relationships and sexual expression far from the top of the list of "things to do." It is crucial to a relationship's survival that a couple set aside priority time for their relationship—if not for lovemaking, then for intimate, quiet contact. Lifestyle variables can also influence the sexual expression of adolescents and young adults. Those with more free time and fewer constructive developmental opportunities (e.g., education, sports, community service) are more likely to engage in risky sexual behavior.

Culturally Mediated Considerations

Nurses should be aware that patients act and behave in various ways, in part because of the influence of culture on behaviors and attitudes. However, although certain attributes and attitudes are frequently associated with particular cultural groups, it is important to remember that not all people from the same cultural background share the same behaviors and views. Although nurses who fail to consider patients' cultural preferences and beliefs are considered insensitive and possibly indifferent, nurses who assume that all members of any one culture act and behave in the same way run the risk of stereotyping people. As stated previously, the best way to avoid stereotyping is to view each patient as a person and to assess the patient's cultural preferences. A thorough cultural assessment using a culture assessment tool or questionnaire can be beneficial.

Health Status and Lifestyle

Obviously, the general health status of a person and specific lifestyle can influence a person's health. Health status may be a factor soon after birth. Societal shifts, triggered by a greater focus on education and careers, have resulted in a trend toward delayed childbearing in American women. This timing has increased the incidence of multiple births due to the increased use of in vitro fertilization and other assisted reproductive technologies along with women delaying childbearing until they are older. Up to 5% of children in the United States are conceived through assisted reproductive technology currently and this percentage will be increasing (Pierce & Mocanu, 2018). Potential complications of multiple births include prematurity and intrauterine growth restriction, which may lead to chronic health problems in the child. Children with chronic health conditions may also have developmental delays, especially in acquiring skills related to cognition, communication, adaptation, social functioning, and motor functioning. Thus, the beginning health status of a child may affect his or her long-term health and development.

Mouth, Nose, Sinuses

Oral diseases are prevalent in poorer populations in developed and developing countries. They include dental caries, periodontal disease, tooth loss, oral mucosal and oropharyngeal lesions and cancers, HIV-related diseases, and trauma. Poor living conditions including diet; nutrition; hygiene; the use of alcohol, tobacco and tobacco-related products; and limited oral health care contribute to developing oral disease. The incidence of oral cancer is different for males and females. The American Cancer Society (ACS, 2015, p. 17) reported that "an estimated 45,780 new cases of cancer of the oral cavity and pharynx (throat) are expected in 2015. Incidence rates are more than twice as high in men as in women. From 2007 to 2011, incidence rates among Whites increased in men by 1.3% per year and were stable as is in women; in contrast, among Blacks rates declined by 3.0% per year in men and by 1.4% per year in women. The increase among White men is driven by a subset of cancers in the oropharynx, including the base of the tongue and the tonsils, which are associated with human papillomavirus (HPV) infection." Although the rate of oral cancer is decreasing among African Americans, throughout the rest of the world, oral cancer is among the most prevalent cancers (WHO, 2016/2005). As in the United States, the rate is higher in males than in females and key risk factors are chewing tobacco use, smoking tobacco use, and alcohol consumption. Therefore, incidence of oral cancer is attributed to environment rather than genetics. Very high rates (five to six times higher than in the United States) are reported for South Asia, where tobacco mixed with betel nut, lime, spices, perfumes, and other substances is used for smoking and chewing (Mukherjee, 2004-2006). This practice is also used in South Asian rituals. Sinusitis is widespread. However, the prevalence is higher in Caucasians and African Americans than in Hispanics

Promoting Responsible Sexual Expression

Patients need to know how to gain satisfactory sexual experiences while behaving responsibly in their activities. Responsible sexuality encompasses sexual expression, prevention of unwanted pregnancy, prevention of STIs, and sex education.

Factors Influencing Nutritional Status in Various Situations

Patients who are hospitalized may have an inadequate dietary intake because of the illness or disorder that necessitated the hospital stay. Patients who are at home may feel too sick or fatigued to shop and prepare food, or they may be unable to eat because of other physical problems or limitations. Limited or fixed incomes or the high costs of medications may result in insufficient money to buy nutritious foods. Culturally influenced food patterns can also affect nutritional status. Because complex treatments (e.g., mechanical ventilation, intravenous infusions, chemotherapy) once used only in the hospital setting are now being provided in the home and outpatient settings, nutritional assessment of patients in these settings is an important aspect of home and community-based care.

Observance of holidays

People from all cultures observe certain civil and religious holidays. Nurses should familiarize themselves with major observances for members of the cultural groups they serve. Information about these observances is available from various sources, including religious organizations, hospital chaplains, and patients themselves. Routine health appointments, diagnostic tests, surgery, and other major procedures should be scheduled to avoid observances that patients identify as significant. If not contraindicated, efforts should also be made to accommodate patients and families or significant others who wish to perform cultural and religious rituals in the health care setting.

surgical management

People who are transgender have many different gender reassignment surgeries available to them as they transition from their sex assigned at birth to their gender identity (Table 54-4). Just like hormone treatment, gender reassignment surgeries help reduce gender dysphoria and improve quality of life. The WPATH (2012) recommends that people who are seeking gender reassignment surgeries meet certain criteria. They recommend that the person seeking surgery have (a) persistent, well-documented gender dysphoria; (b) capacity to make a fully informed decision and to give consent for treatment; (c) age of majority in a given country; and (d) any significant medical or mental health concerns be well controlled. For certain surgeries, including hysterectomy, phalloplasty, and vaginoplasty, WPATH (2012) also recommends that the person has had 12 continuous months of hormone therapy and has had 12 continuous months of living in a gender role that is congruent with their gender identity. This is based on clinical consensus, not empirical evidence, that living 12 months in a gender role that is congruent with their gender identity gives them ample opportunity to experience and socially adjust before undergoing irreversible surgery

Assessment and Management of Patients Seeking Gender Reassignment

People who are transgender may experience gender dysphoria, which is the distress caused by the dissonance between the person's gender identity and that person's sex assigned at birth. To assist people with this distress and find a gender role that is comfortable for them, treatment is available and may include medical and surgical interventions. Treatment is individualized, meaning that interventions that effectively alleviate gender dysphoria in one patient may not work for a different patient. Health care teams who provide psychological, medical, and surgical treatments to people who are transgender often follow the Standards of Care published by the World Professional Association for Transgender Health (WPATH, 2012). Even though the latest version of the Standards of Care was released in 2012, at the time of this book print, it is still the leading resource for the care of people who are transgender. Other important resources include the Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People from the University of California, San Francisco (Deutsch, 2016) and the Principles of Transgender Medicine and Surgery (Ettner, Monstrey, & Coleman, 2016) (see References and Resources sections at the end of the chapter). Providing treatment to people who are seeking gender reassignment almost always starts with confirming a diagnosis of gender dysphoria. Many health insurance companies require a gender dysphoria or related diagnosis before covering the costs of gender reassignment treatments. Gender dysphoria is a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Chart 54-2 lists the criteria used to diagnose a person with gender dysphoria. In short, to be diagnosed with gender dysphoria, a person must exhibit specific thoughts and feelings about the incongruence of their gender identity and their secondary sex characteristics for a period of at least 6 months (American Psychiatric Association, 2013). An experienced mental health care professional, such as a psychiatric mental health nurse practitioner, clinical social worker, psychologist, or psychiatrist, can assess, diagnose, and provide psychological treatment for gender dysphoria. Before a health care provider prescribes medical or surgical treatments (e.g., hormones, gender reassignment surgery), they usually require that the person has consulted with a mental health care provider and received a diagnosis of gender dysphoria. When a person wants to address the distress or other negative emotions associated with having a gender that does not align with their sex assigned at birth (gender dysphoria), they will usually work with an interdisciplinary health care team. This team typically includes a mental health care professional, a health care provider experienced in endocrinology, and a surgeon. The mental health care professional will provide psychological support to the person during their gender identity journey; the endocrinology health care provider will prescribe hormones and monitor outcomes; the surgeon will handle gender reassignment surgeries. Depending on the treatment settings, nurses are involved in various capacities along the treatment continuum

Effective Communication

People who seek health care for a specific problem are often anxious. Their anxiety may be increased by fear about potential diagnoses, possible disruption of lifestyle, and other concerns. With this in mind, the nurse attempts to establish rapport, put the patient at ease, encourage honest communication, make eye contact, and listen carefully to the patient's responses to questions about health issues. When obtaining a health history or performing a physical examination, nurses must be aware of their own nonverbal communication, as well as that of the patient. The nurse should take into consideration the patient's educational background, language proficiency, and cultural background (see following discussion on Cultural Concepts and Cultural Competence). Questions and instructions to the patient should be phrased so that they are easily understandable. Technical terms and medical jargon should be avoided. In addition, the nurse must consider any disability or impairments (hearing, vision, cognitive, and physical limitations). At the end of the assessment, the nurse summarizes and clarifies the information obtained and asks the patient whether they have any questions; this gives the nurse the opportunity to correct misinformation and add facts that may have been omitted.

LGBTQ assessment

Personal Information The nurse introduces these assessment questions by stating: •"I am going to ask you a few questions about your sexual orientation and gender identity so we can provide personalized and affirmative care to you. These are questions I ask every patient. If you do not feel comfortable answering these questions, we can skip them." The nurse assesses for gender identity using a two-step question: •"What sex was listed on your birth certificate?" •"What is your current gender identity?" or "How do you describe your gender identity?" Assessing for pronouns: •"What pronouns do you prefer we use?" •If the patient is unsure of what this means, you can ask, "Do you use the pronouns he/him, she/her, or something else?" Assessing sexual orientation: •"What is your sexual orientation?" or "How do you describe your sexual orientation?" Assessing for preferred name: •"What name do you preferred to be called?" or "What is the name that you would like us to use?"

Space and distance

Personal space is the area that surrounds a person's body and includes the space and the objects within the space (Giger, 2016). People tend to regard the space in their immediate vicinity as an extension of themselves. The amount of space that they need between themselves and others to feel comfortable is a culturally determined phenomenon. Because nurses and patients usually are not consciously aware of their personal space requirements, they frequently have difficulty understanding different behaviors. For example, one patient may perceive the nurse sitting close to them as an expression of warmth and care; another patient may perceive the nurse's act as a threatening invasion of personal space. Research reveals that people from the United States, Canada, and Great Britain require the most personal space between themselves and others, whereas those from Latin America, Japan, and the Middle East need the least amount of space and feel comfortable standing close to others (Giger, 2016). If the patient appears to position himself or herself too close or too far away, the nurse should consider cultural preferences for space and distance. Ideally, the patient should be permitted to assume a position that is comfortable to them in terms of personal space and distance. The nurse should be aware that the wheelchair of a person with a disability is considered an extension of the person; therefore, the nurse should ask the person's permission before moving or touching the wheelchair. Because a significant amount of communication during nursing care requires close physical contact, the nurse should be aware that having personal space promotes self-identity by allowing opportunities for patient self-expression (Giger, 2016).

menarche:

initiation of the menstrual cycle

intercourse:

insertion of the penis into the partner's vagina, anus, or mouth

Points to Consider When Working on Therapeutic Communication Skills

Remember that nonverbal communication is just as important as the words you speak. Be mindful of your facial expression, body posture, and other nonverbal aspects of communication as you work with clients. •Ask colleagues for feedback about your communication style. Ask them how they communicate with clients in difficult or uncomfortable situations. •Examine your communication by asking questions such as "How do I relate to men? To women? To authority figures? To elderly persons? To people from cultures different from my own?" or "What types of clients or situations make me uncomfortable? Sad? Angry? Frustrated?" Use these self-assessment data to improve your communication skills.

age and gender

Research has demonstrated that the nervous system structures needed for pain impulse transmission and perception are present before birth (Anand, 2019; Sekulic et al., 2016). Therefore, children of any age, including preterm newborns, are capable of experiencing pain. Early on, children can interpret pain as an unpleasant sensation, but this interpretation is based on their comparison with other sensations. As they get older, they learn to use words to describe their pain more fully. Gender and sex also may play a role in a child's perception of pain, but most of the research has been performed on adults; therefore, whether it holds true for children is unclear (Zagni et al., 2016). It has been suggested that boys and girls differ in how they perceive, experience, express, and cope with pain and respond to analgesics. This may be influenced by various factors including genetics, hormones, family, and culture. Further research is warranted in this area to allow for more focused care in pain management.

Gentitalia, Anus, Rectum, Prostate

Sexually transmitted infections (chlamydia, herpes, human papilloma virus [HPV], syphilis, gonorrhea, and HIV/AIDS) vary across U.S. populations. Ethnic variation is thought to be due to rates of poverty, income inequality, unemployment, low educational attainment (CDC, 2014), use of drugs (CDC, 2016d), and other factors, but essentially to risky sexual behavior (Dariotis et al., 2011). Dariotis and colleagues reported that African American and Latino men had the consistently highest rate of sexual risk and STDs relative to their Caucasian peers, and this pattern remained even after controlling for sociodemographic variables. HIV/AIDS infection remains highest in sub-Saharan Africa, followed by Asia and the Pacific. The number of people living with HIV is highest in South Africa but other surrounding countries have high rates as well (Henry J. Kaiser Family Foundation, 2015). The highest incidence of cervical cancer in the United States is among Hispanics and African Americans, and the lowest is among Asian/Pacific Islanders, and Native Americans/Alaska Natives, but death rates were highest among African Americans (CDC, 2016b). In U.S. populations, incidence of prostate cancer is highest among African Americans and lowest among Native Americans/Alaska Natives, while the death rate follows the same pattern (CDC, 2016e). Forman et al. (2012) and WHO (2015a) reported worldwide prevalence of HPV and cervical cancer with the following findings: HPV infection has been identified as a definite human carcinogen for six types of cancer: cervix, penis, vulva, vagina, anus, and oropharynx (including the base of the tongue and tonsils). Cervical cancer is the third most common female malignancy and shows a strong association with level of development, rates being at least fourfold higher in countries defined within the low ranking of the Human Development Index (HDI) compared with those in the very high category; HPV varies accordingly but even in women without cervical abnormalities, HPV is most prevalent in sub-Saharan Africa, Eastern Europe, and Latin America.

Spiritual and Cultural Beliefs

Showing respect for a patient's cultural values and beliefs facilitates rapport and trust. Assessment includes identifying the ethnic group to which the patient relates and the customs and beliefs the patient holds about illness and health care providers. Knowledge of the patient's physiologic, psychosocial, cultural, spiritual, and educational needs allows the perioperative nurse to provide a holistic approach to care. A holistic picture of the patient allows the perioperative nurse the opportunity to identify patient care issues that extend beyond the medical diagnosis and planned surgical procedure and choose a nursing diagnosis based on key elements of the patient's needs and goals. The nurse advocates for the patient and develops a holistic care plan that is communicated to members of the intraoperative and postoperative team. Perioperative patient advocacy entails paying respect to other human beings, preserving the patient's expressed values, and treating all patients equally (Sundqvist, Holmefur, Nilsson, et al., 2016). Certain ethnic groups are unaccustomed to expressing feelings openly with strangers, and nurses need to consider this pattern of communication when assessing pain. In some cultural groups, it is seen as impolite to make direct eye contact with others and doing so is seen as disrespectful. The nurse should know that this lack of eye contact is not avoidance nor does it reflect a lack of interest. Other ethnicities view the top of the head as sacred; therefore, a nurse would not put the surgical cap on the patient but would ask the patient to don the cap. Perhaps the most valuable skill at the nurse's disposal is listening carefully to the patient and observing body language, especially when obtaining the history. Invaluable information and insights may be gained through effective communication and interviewing skills. An unhurried, understanding, and caring nurse promotes confidence on the part of the patient.

situational factors

Situational factors involve factors or elements that interact with the child and his or her current situation involving the experience of pain. These factors are highly variable and dependent on the specific situation. Situational factors result from the context in which the child is experiencing pain and include cognitive, which is what the child understands and believes about the pain experience; behavioral, which is how the child and family react and what they do about the pain experience; and emotional, which is how the child and family feel about the pain experience (McGrath, 2005). Due to children's limited experience with pain, situational factors may affect them more than adults (McGrath, 2005). A thorough pain assessment must include assessment for situational factors that may exacerbate pain. Examples of situational factors include: Child's lack of understanding of the source of pain Child's lack of ability to use coping mechanisms or pain-relieving strategies to decrease pain Stress and anxiety in anticipation of pain Child's lack of control of cause of pain Child's lack of ability to understand what to expect from potentially painful experiences Increased anxiety exhibited by the family Overly protective behaviors exhibited by the family Presence of emotions such as fear, anxiety, frustration, distress, underlying anxiety, and depression

High blood

Slang term for high blood pressure, but also for thick or excessive blood that rises in the body. Often believed to be caused by overly rich foods.

Socioeconomic Status and Social Class

Socioeconomic status refers to one's income, education, and occupation. It strongly influences a person's health, including whether or not the person has insurance and adequate access to health care or can afford prescribed treatment. People who live in poverty are also at risk for threats to health, such as inadequate housing, lead paint, p. 122p. 123 gang-related violence, drug trafficking, or substandard schools. Social class has less influence in the United States than in some other countries because barriers among the social classes are loose and mobility is common; people can gain access to better schools, housing, health care, and lifestyle as they increase their income. In many other countries, however, social class is fixed and can be a powerful influence on social relationships and can determine how people relate to one another, even in a health care setting. For example, a caste system exists in India, and people in the lowest caste may feel unworthy or undeserving of the same level of health care as people in higher castes. The nurse must determine whether social class is a factor in how clients relate to health care providers and the health care system.

Religion with sex

Some people view organized religion as having a generally negative effect on the expression of sexuality. For example, in many religions, the concept of virginity came to be synonymous with purity, and sex became synonymous with sin. In addition, many forms of sexual expression other than male-female coitus are considered unnatural by some religions. As a result of the rigid regulations and negative connotation of sex dictated by some religious groups, a number of sexual dysfunctions can be related to a person's resulting guilt and anxiety. Most major religions are reexamining their teachings on sexuality in response to challenges posed by their members. Organized religions, such as Catholicism, have public figures who are moving toward gender inclusivity by accepting and having frank conversations with and about the LGBT (Lesbian, Gay, Bisexual, Transgender) communities (Martin, 2017). Many people have recognized the importance of solid sex education within the realm of the church and organized religions. There is also a new interest in the spirituality of marriage: churches and organized religions are examining their role in supporting the intimate sexual relationship of married couples.

Spirituality and Religion

Spirituality is a basic human quality involving the belief in something greater than oneself and a faith that affirms life positively. It is a major influence in many people's lives, providing a meaning or purpose to life and a foundation for and source of love, relationships, and service. Spirituality is considered a universal human phenomenon with an assumption of the wholeness of people and their connectedness to a higher being. During life-changing events and crises, such as a serious illness or the birth of a child with a congenital defect, families often turn to spirituality for hope, comfort, and relief. The word religion is often used interchangeably with spirituality in our society. However, spirituality is a more private and individual belief, whereas religion is an organized way of sharing beliefs and practicing worship. Around 80% of Americans believe in God (Pew Research Center, 2018). Therefore, spirituality and religion are an important focus when working with women, children, and their families. A person's reaction to health and illness may be affected by these beliefs. In some religions, illness is seen as a punishment for sin or wrongdoing. Other religions view illness as a test of strength (Nies & McEwen, 2019). People appreciate the recognition of, and respect for, their beliefs. Therefore, identifying the individual's and family's religious beliefs and customs is important. People may adhere to special dietary restrictions, rituals such as baptism or Holy Communion, use of amulets or icons, or practices related to dying that can be incorporated into the plan of care. Using open-ended questions and observing for the use of religious articles during assessment can provide clues to the family's beliefs and practices. Visits from spiritual leaders may also be noted. Table 1.5 identifies some of the ways in which tenets of major religious beliefs may affect children's health.

Spirituality

Spirituality is closely associated with culture and includes religious practices, faith, and a relationship with God or a higher being and those things that bring meaning to life.

Spiritual environment

Spirituality is defined as connectedness with self, others, a life force, or God that allows people to experience self-transcendence and find meaning in life. Spirituality helps many people discover a purpose in life, understand the ever-changing qualities of life, and develop their relationship with God or a higher power. Spirituality in nursing practice includes concerns with the personal spiritual and religious needs of the patient and nurse, as well as the spiritual dimension of the nurse-patient interaction (O'Brien, 2017). Spiritual behavior can be expressed through devotion, sacrifice, self-discipline, and spending time in activities that focus on the inner self or the soul. Although religion and nature are two vehicles that people use to connect themselves with God or a higher power, bonds to religious institutions, beliefs, or dogma are not required to experience the spiritual sense of self. Faith, considered the foundation of spirituality, is trust in God and belief in a higher power or something that a person cannot see. The spiritual part of a person views life as a mystery that unfolds over one's lifetime, encompassing questions about meaning, hope, relatedness to a higher power, acceptance or forgiveness, and transcendence. A person's spiritual environment refers to the degree to which they think about or contemplate existence, accept challenges in life, and seek and find answers to personal questions. Spirituality may be expressed through identification with a particular religion. Spiritual values and beliefs often direct a person's behavior and approach to health problems and can influence responses to sickness. A strong sense of spirituality or religious faith can have a positive impact on health. Spirituality is also a component of hope, and, especially during chronic, serious, or terminal illness, patients and their families often find comfort and emotional strength in their religious traditions or spiritual beliefs. At other times, illness and loss can cause a loss of faith or meaning in life and a spiritual crisis, which can place considerable stress on a person's internal resources and beliefs. It is important that the spiritual beliefs of people and families be acknowledged, valued, and respected for the comfort and guidance they provide. Inquiring about spirituality can identify possible support systems as well as beliefs and customs that need to be considered in planning care. Information is gathered about the extent to which religion is a part of the person's life as well as religious beliefs and practices related to health and illness. A spiritual assessment may involve asking the following questions: Is religion or spirituality important to you? If no, what is the most important thing in your life? If yes, in what way? For instance: Are there any religious or spiritual practices that are important to you? Do you belong to a faith community or have a place of worship? Do you have any religious or spiritual concerns because of your present health problem? The nurse should assess spiritual strength further by inquiring about the patient's sense of spiritual well-being, hope, and peacefulness. It is also necessary to assess whether spiritual beliefs and values have changed in response to illness or loss. The nurse assesses current and past participation in religious or spiritual practices and notes the patient's responses to questions regarding spiritual needs to help determine the patient's need for spiritual care. Another simple assessment technique is to inquire about the patient's and family's desire for spiritual support (O'Brien, 2017).

Peripheral vascular system

Studies of risks for chronic venous disease have remained hard to determine, according to Criqui et al. (2007). However, African American ethnicity seems to confer a protective effect. A physiologic difference in the number of lower leg veins (Africans have a higher number than do Caucasians) has been thought to account for the lower prevalence rates of varicose veins in people of African descent (1% to 2%) than in Caucasians (10% to 18%)

Breasts and Lymphatic System

The CDC (2016a) reported a study of female breast cancer survivors and incidence and prevalence of breast cancer in the United States, noting results as follows: In 2013, Caucasian women had the highest rate of developing breast cancer, followed by African American, Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native women. As for death from breast cancer, in 2013, African American women were more likely to die of breast cancer than any other group, followed by Caucasian, Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native women. There are some differences in beliefs about causes of breast cancer that vary by culture. A qualitative study by Gonzalez et al. (2015) using a focus group of Chinese, Korean, and Mexican American women found similar beliefs about cause: stress, diet, and fatalism. An interesting study done in Australia examining beliefs about causes of breast cancer compared beliefs of women without breast cancer and those with breast cancer (Thomson et al., 2014). Women without breast cancer attributed the cancer to familial and inherited factors, followed by lifestyle factors (poor diet, smoking), and environmental factors (such as food additives). Women with breast cancer attributed the cancer to mental or emotional factors (especially stress), followed by lifestyle factors and physiologic factors particularly related to hormonal history.

National Standards for Care

The Office of Minority Health has created standards that recommend voluntary acceptance by health care organizations of adopting standards to create systems that provide culturally and linguistically appropriate care for all persons seeking their service. Federal funds depend on adherence to the standards, thus the level of voluntary acceptance is more a mandate. Individuals who work within the health care systems are expected to follow these standards as well. "The 14 standards (known as CLAS mandates) are organized by themes: Culturally Competent Care (Standards 1 through 3), Language Access Services (Standards 4 through 7), and Organizational Supports for Cultural Competence (Standards 8 through 14). Within this framework, there are three types of standards of varying stringency: mandates, guidelines, and recommendations" (Office of Minority Health, 2001). Box 11-2 provides the standards.

Changing Cultural Demographics

The United States is no longer a melting pot of various cultures and ethnicities but a society with each individual bringing a diversity and richness that enriches the country as a whole. Currently, there are approximately 19 million immigrant children from birth to 17 years old in the United States of which, 51% of the population is White, 14% is Black or African American, 25% is Hispanic, 5% is Asian, and 5% is non-Hispanic other races (FIFCFS, 2017). The Hispanic population has increased substantially over the past decade (FIFCFS, 2017). It is projected by 2050 that 36% of the U.S. population of children will be Hispanic and 36% will be White, non-Hispanic (FIFCFS, 2017). In addition, the increasing number of intermarriages between individuals from different ethnic origins is producing an increasing number of children who have a heritage that represents more than one cultural group.

Ears

The WHO (2015b) recorded that there are 360 million people across the world who have disabling hearing loss, and half of all cases are avoidable through primary prevention. Hearing loss may result from genetic causes, complications at birth, certain infectious diseases, chronic ear infections, the use of particular drugs, exposure to excessive noise and aging. As for aging, approximately one third of those over 65 years of age are affected by disabling hearing loss. There have been reports that populations with shorter, wider, and more horizontal eustachian tubes (Native Americans, Eskimos, New Zealand Maoris, one Nigerian population, and some aborigines) have higher rates of otitis media (Casselbrant et al., 1995). Shireman and Kelsey (2002) reported that African Americans have lower rates of otitis media than do Caucasians. According to WHO (2015b), causes of hearing loss at or before birth may be from birth complications such as prematurity, reduced oxygen for the baby, or mother's infections (e.g., rubella, syphilis); use of drugs affecting the baby's hearing (more than 130 drugs including gentamicin); and severe jaundice, which can damage the baby's hearing nerve. After birth, infectious diseases, ototoxic drugs, head or ear injury, wax or foreign body blockage, excessive noise, and age can lead to hearing loss.

Vaginal intercourse

The act of placing the penis in the vagina, penile-vaginal intercourse, can be accomplished in various positions. The most common position in Western cultures is the "missionary position," in which the woman lies horizontally underneath the man. You may find it interesting that the Polynesians named this position because it was the preferred position for intercourse used by religious missionaries. Couples may find other positions to be more stimulating and comfortable. Clitoral stimulation is difficult to achieve in the missionary position. Lying side by side, female on top, and rear entry are some examples of coital positions that enable clitoral stimulation. Sexually inhibited people may believe they need permission to engage in alternative sexual positions. When the penis is pushed into the vagina, the man begins rhythmic thrusting movements of his hips to move the penis back and forth along the vaginal walls. The woman might match her partner's hip movements with movements of her own body. These movements continue until orgasm is attained by one person or both. Simultaneous orgasms, or both people attaining orgasm at the same moment, are difficult to achieve. A preoccupation with attaining simultaneous orgasms might disrupt the ultimate intimacy and satisfaction possible during coitus. The period after coitus is just as significant as the events leading up to it. Caressing, hugging, and kissing deepen the couple's intimacy and should be nurtured, not rushed.

What Can You Do to Prevent STIs?

The best way to prevent STIs is to avoid sexual contact with others. If you decide to be sexually active, there are things that you can do to reduce your risk of developing an STI. Have a mutually monogamous sexual relationship with an uninfected partner. Correctly and consistently use a male condom. Use clean needles if injecting intravenous drugs. Prevent and control other STIs to decrease susceptibility to HIV infection and to reduce your infectiousness if you are HIV infected. Delay having sexual relations as long as possible. The younger people are when having sex for the first time, the more susceptible they become to developing an STI. The risk of acquiring an STI also increases with the number of partners over a lifetime. Anyone who is sexually active should: Have regular checkups for STIs even in the absence of symptoms, and especially if having sex with a new partner. These tests can be done during a routine visit to the doctor's office. Learn the common symptoms of STIs. Seek medical help immediately if any suspicious symptoms develop, even if they are mild. Avoid anal intercourse, but if practiced, use a male condom. Avoid douching because it removes some of the normal protective bacteria in the vagina and increases the risk of getting some STIs. Anyone diagnosed as having an STI should: Be treated to reduce the risk of transmitting an STI to a sex partner or from mother to baby. Discuss with a doctor the possible risk of transmission in breast milk and whether commercial formula should be substituted. Notify all recent sex partners and urge them to get a checkup. Follow the provider's orders and complete the full course of medication prescribed. A follow-up test to ensure that the infection has been cured is often an important step in treatment. Avoid all sexual activity while being treated for an STI. Sometimes people are too embarrassed or frightened to ask for help or information. Most STIs are readily treated. The earlier a person seeks treatment and warns sex partners about the disease, the less likely the disease will do irreparable physical damage, be spread to others, or, in the case of a woman, be passed on to a newborn baby.

Cultural Concepts

The concept of culture and its relationship to the health care beliefs and practices of patients and their family or significant others provide the foundation for transcultural nursing. This awareness of culture in the delivery of nursing care has been described in different terms and phrases, including respect for cultural diversity or cultural humility; cultural awareness or sensitivity; comprehensive care; cultural consciousness or culturally congruent nursing care (Alexander-Ruff & Kinion, 2019; Henderson, Horne, Hills, et al., 2018). Culture is commonly defined as the knowledge, belief, art, morals, laws, customs, and any other capabilities and habits acquired by humans as members of society. Such groups may distinguish themselves by socioeconomic class, race, ethnicity, religion, gender, sexual orientation, nationality, physical disability, or some other specific characteristic (Fioravanti, Puskar, Knapp, et al., 2018). During the past century, many other definitions of culture have been offered that integrate these themes as well as the themes of ethnic variations of a population. Culture also implies that something is learned or developed, a process that occurs over time. Leininger (2002), founder of the specialty known as transcultural nursing, noted that culture involves learned and transmitted knowledge about values, beliefs, rules of behavior, and lifestyle practices that guide designated groups in their thinking and actions in patterned ways. Culture guides each person's thinking, doing, and being, and becomes patterned expressions of who that person is and becomes. Ethnicity is defined as an affiliation relating to large groups of people classed according to common racial, national, tribal, religious, linguistic, or cultural background. Ethnic culture has four basic characteristics: Learned from birth through language and socialization Shared by members of the same cultural group, and it includes an internal sense and external perception of distinctiveness Influenced by specific conditions related to environmental and technical factors and to the availability of resources Dynamic and ever changing With the exception of the first characteristic, culture related to age, physical appearance, and lifestyle, as well as other less frequently acknowledged aspects, also shares these characteristics.

Head and Neck

The few cultural considerations that come into play are related to dependence on poorly maintained automobiles or bicycles, lack of use of protective gear, inadequate and unsafe housing, and unsafe celebratory practices (such as shooting guns to welcome the new year). In the United States, traumatic brain injury (TBI) is especially prevalent among adolescents, young adults, and persons over 75 years of age, with males more than twice as much at risk as females. The Centers for Disease Control and Prevention (CDC, 2010) reported that falls continue to be the leading cause of TBI in the United States, causing 50% of TBIs for ages 0 to 4 years and 61% for those over 65 years. The second cause of TBI for all ages is motor vehicle accidents or traffic-related incidents. Assaults (especially firearms), head strikes, and unknown events make up the remainder of TBIs.

Assimilation

The gradual adoption and incorporation of characteristics of the prevailing culture.

LITERACY ISSUES

The greatest barrier to understanding anything is the inability to read. Adequate literacy skills are essential for client and family education, yet many people in America today have marginal reading capabilities. In the United States, more than 36 million adults cannot read better than the average third grader (ProLiteracy, n.d.). Even people with adequate literacy skills may have difficulty reading, understanding, and applying information to health care situations (Fig. 2.2). Health literacy is the ability to read, understand, and use health care information to make appropriate health care decisions and successfully navigate the health care system (Health Resources & Services Administration [HRSA], 2019). It is not simply having the ability to read the health care information, but also includes listening; displaying oral, analytic, and decision-making skills; using electronic technology; and applying these skills to health care situations. The inability to read and comprehend health care information is an enormous problem for many Americans today, with nearly half of all American adults having limited health literacy (American Academy of Pediatrics [AAP], 2020). Low health literacy affects people of all ages, races, and educational and income levels and results in increased hospitalizations, decreased health status, and increased health costs (Weiss, 2014). Medical information is becoming increasingly complex, while the amount of time nurses have to spend with clients is decreasing. Also, when unfamiliar information is introduced or when emotional distress is present, reading ability and understanding are further reduced. Therefore, all health care providers should use universal literacy precautions and focus on providing easy to understand information during every patient encounter. Poor literacy and health literacy skills are difficult to recognize: appearance, verbal ability, employment status, and educational level cannot reliably detect person's literacy or health literacy abilities. Many people who do not read well go to great lengths to hide their disability. Poor health literacy affects all segments of the population, but certain groups such as the elderly, the poor, members of minority groups, medically underserved, and people who speak English as a second language are at a higher risk (Health Resources & Services Administration [HRSA], 2019). Red flags that might indicate poor literacy skills include the following (Davis et al., 2017; HRSA, 2019): Difficulty filling out registration forms, questionnaires, and consent forms; forms are incomplete, incorrect, or inaccurate. Frequently missed appointments Noncompliance and lack of follow-up with treatment regimens History of medication errors Responses such as, "I forgot my glasses" or "I'll read this when I get home" Inability to answer common questions about their treatment or medicines Avoiding asking questions for fear of looking "stupid" Nurses need to provide understandable and accessible information to all clients, regardless of their literacy or education levels. This would include avoiding medical jargon, breaking down information or instructions into small concrete steps, limiting the focus of a visit to three key points or tasks, and assessing for comprehension. In addition, printed information should be written at or below a 5th to 6th grade reading level with plenty of visual aids or pictures (Wittenberg et al., 2018).

Health Care Needs of Lesbian, Gay Male, Bisexual, and Transgender People

The health and well-being of lesbian, gay male, bisexual, and transgender (LGBT) people has been made a priority by major federal health care facilities. The term LGBT has been expanded to LGBTQIA (Lesbian, Gay, Bisexual, Transgender/Transsexual, Questioning/Queer, Intersex, Ally/Asexual), but the terms associated with the acronym vary slightly depending on the source. The Institute of Medicine's consensus report (IOM, 2011), Healthy People 2020 (2018b), and USDHHS (2016) all highlight the need for better science-based knowledge on how best to address the existence of health disparities of LGBT people and the lack of compassionate services. Stigma and a range of other social and cultural factors affect the health of LGBT people, as well as the ability of the health care system and providers to care for them. LGBT people come from diverse cultural backgrounds, have varied ethnic or racial identity, and differ in terms of education, age, income, and place of residence. Those who identify as lesbian, gay, bisexual, or other may be defined by their sexual orientation, but this definition is complex and variable. Sexual behavior, cultural factors, disclosure of sexual orientation and/or gender identity, prejudice and discrimination, and concealed sexual identity each present unique health challenges to this population (Box 45-3 on page 1780). Other issues that affect health care delivery to the LGBTQIA population include the following: Public health infrastructure: Efforts to research and address the health care needs of LGBTQIA people are hindered by an inadequate infrastructure to support and fund population-specific initiatives. Access to quality health services: Financial, structural, personal, and cultural barriers limit access to screening and prevention services and cause delays in care for acute conditions in the LGBTQIA population. Health communication: Negative provider attitudes, lack of provider education regarding unique aspects of lesbian and gay health, and exclusion of same-sex partners in care planning seriously hamper therapeutic communication between members of the LGBTQIA community and those who provide care. Educational and community-based programs: Some government facilities, professional organizations, and health care organizations address health issues of the LGBTQIA community, but this population still relies heavily on self-created community-based programs to address their special health care requirements. Clearly, significant research is needed regarding the unique experience and health care needs of the LGBT population, along with increased education for health care providers. Issues of prejudice and inequitable service distribution in the health care system need to be addressed to improve the health of this population.

Influences on Health Care Delivery

The health care delivery system is constantly adapting to changes in health care needs and expectations. Shifting population demographics; changing patterns of disease and wellness; advances in technology and genetics; and greater emphasis on health care quality, costs, reform efforts, and interprofessional collaborative practices have impacted health care delivery and the practice of nursing.

Cultural imposition

The intrusive application of the majority group's cultural view upon individuals and families (citing the United Nations, 1948, Universal Declaration of Human Rights).

Culture in sex

The manner in which a society perceives sexuality influences the person. Every culture has its own norms regarding sexual identity and behavior. To some degree, culture dictates the choice of sexual partner, duration of sexual intercourse, methods of sexual stimulation, and sexual positions. In some cultures, women may be expected to merely tolerate sex; in others, the woman's participation is encouraged. To gain an appreciation for all the ways that culture can influence sexual expression and health, ask people from different cultures the following questions: What type of dress is appropriate for children, men, and women? How is nudity viewed? What role behaviors and social responsibilities are expected of men and women? Is masturbation acceptable? At what age is genital sexual intimacy appropriate? With whom is it appropriate? What sexual practices are accepted? What are the rules for marriage? Is premarital sex, extramarital sex, or polygamy accepted?

The Nursing Process

The maternal and pediatric nurse performs all of these tasks using the framework of the nursing process. The nursing process is used to care for the woman, child and family during health promotion, maintenance, restoration, and rehabilitation. It is a problem-solving method based on the scientific method that allows nursing care to be planned and implemented in a thorough, organized manner to ensure quality and consistency of care. The nursing process is applicable to all health care settings and consists of five steps: assessment, nursing analysis (diagnosis), outcome identification and planning, implementation, and outcome evaluation. Assessment. Assessment involves collecting data about the woman, child and family and performing physical assessment during community-based health services, at admission to an acute care setting, at periodic times during the child's hospitalization or care, and during home care visits. Analysis. The nurse analyzes the assessment data to make judgments about the woman's or child's health and developmental status. From this analysis, the nurse develops a list of client issues, concerns, problems, opportunities, or nursing analyses, which differ from medical diagnoses in that they are issues the nurse can address within their scope of practice. This clinical judgment process describes health promotion and health patterns that maternal and pediatric nurses can manage. Planning and expected outcomes. The next step in the process involves developing a plan of care that incorporate goals or expected outcomes that improve the woman's or child's dysfunctional health patterns, promote appropriate health patterns, or provide for optimal developmental outcomes. The plan of care includes the specific nursing actions that assist in obtaining the outcomes. Implementation. These interventions are implemented, adapted to the child's developmental level and family status, and modified if the woman's or child's response indicates the need. The care plan incorporates the family in addition to the woman or child. Evaluation. The process is continually evaluated and updated during the partnership with the woman, child and family. Standardized care plans for specific nursing analyses/client issues or concerns and critical pathways for case management are often used in various maternal and pediatric settings. In general, care plans and critical pathways are becoming more evidence based, using a combination of research, group consensus, and past health care decisions to identify the most effective interventions for the woman, child and family. Evidence-based care planning systems or tools can help bring EBPs to the point of care. These templates can help improve the quality of patient care. The nurse is responsible for individualizing these standardized care plans based on the data collected during the assessment of the woman or child and family and for evaluating the woman's or child's and family's response to the nursing interventions.

SEXUAL EXPRESSION

The methods by which people gain satisfaction through sexual stimulation are varied. Touches, smells, sights, sounds, feelings, thoughts, and fantasies can all contribute to sexual fulfillment in any form of expression chosen by people. Feelings of love for another person are closely associated with desire (Fig. 45-1). Forms of sexual stimulation include kissing, hugging, stroking, squeezing, breast stimulation, manual stimulation of the genitals, oral-genital stimulation, and anal stimulation. Sexual stimulation may be physical or psychological. Erotic stimulation through the use of films, magazines, and photographs is common. Fetishism, more often practiced by males, is sexual arousal with the aid of an inanimate object not generally associated with sexual activity. Items such as shoes, leather, rubber, and women's undergarments might be used. On a continuum, sexual behavior ranges from adaptive to maladaptive. Adaptive responses meet the following criteria: Between two consenting adults Mutually satisfying to both Not psychologically or physically harmful to either Lacking in force or coercion Conducted in private Maladaptive sexual responses are behaviors that do not meet one or more of the criteria for adaptive responses

CULTURAL FACTORS

The need for health care practitioners to provide culturally competent care has continually increased in the American health care system. The diversity of the U.S. population has resulted in new, larger ethnocultural groups, a mosaic rather than a melting pot (Cultural Savvy, 2019). Culturally competent nursing care means being sensitive to issues related to culture, race, gender, sexual orientation, social class, economic situation, and other factors. Nurses and other health care providers must learn about other cultures and become skilled at providing care to people with cultural backgrounds that are different from their own. Finding out about another's cultural beliefs and practices and understanding their meanings are essential to providing holistic and meaningful care to the client.

Psychosocial Factors

The nurse anticipates that most patients have emotional reactions prior to surgery—obvious or veiled, normal or abnormal. Fear may be related to the unknown, lack of control, or of death and may be influenced by anesthesia, pain, complications, cancer, or prior surgical experience. Preoperative anxiety can be a preemptive response to a threat to the patient's role in life, a permanent incapacity or body integrity, increased responsibilities or burden on family members, or life itself. Less obvious concerns may occur because of previous experiences with the health care system and people the patient has known with the same condition. Psychological distress directly influences body functioning. Identification of anxiety by the health care team using supportive guidance at every juncture of the perioperative process helps to ease anxiety. Research suggests that negative postoperative outcomes can result from fear and anxiety preoperatively. Anxiety triggers a physical response, stimulating the release of epinephrine and norepinephrine, which in turn raises blood pressure and increases heart rate, cardiac output, and blood glucose levels. Therefore, overall healing may be impaired while pain and risk of infection may increase postoperatively (Bagheri, Ebrahimi, Abbasi, et al., 2019). People express fear in different ways. Some patients may ask repeated questions, regardless of information already shared with them. Others may withdraw, deliberately avoiding communication by reading, watching television, or talking about trivialities. Consequently, the nurse must be empathetic, listen well, and provide information that helps alleviate concerns. An important outcome of the psychosocial assessment is the determination of the extent and role of the patient's support network. The value and reliability of available support systems are assessed. Other information, such as knowledge of the usual level of functioning and typical daily activities, may assist in the patient's care and recovery. Assessing the patient's readiness to learn and determining the best approach to maximize comprehension provide the basis for preoperative patient education. This is of particular importance in patients who are developmentally delayed and those who are cognitively impaired, where the approach to patient education and consent will include the legal guardian.

Postoperative Education for Patients Who Have Had a Vaginoplasty

The nurse instructs the patient about activity, bathing, swelling, hygiene, and vaginal intercourse as described below. Activity •Avoid strenuous activity for 6 weeks •Avoid swimming or bike riding for 3 months •May be uncomfortable to sit for the first month; may use donut ring to relieve pressure Bathing •Resume showering following first postoperative visit •Do not submerge groin area in water for 8 weeks Swelling •Labial swelling is normal and will resolve in 6 to 8 weeks •Apply ice to perineum for 20 minutes every hour while awake for 1 week postoperatively •Increased swelling with pain should be reported to surgeon Hygiene •Wash hands before and after contact with genital area •Wipe genital area from front to back to avoid contamination by bacteria from anal region Vaginal Intercourse •May engage in vaginal intercourse 3 months after surgery

old age

The synthesis and secretion of many endogenous hormones change and the expression of cell receptors in tissues changes in numbers and signaling capacity as the human body ages (Houlberg, 2019). Although there is very little research on the effect of exogenous cross-sex hormones in older adults who are transgender, there are important considerations given the endocrine changes in aging bodies. The major consideration for nurses is the effects of sex steroids on the metabolism of medication. With aging, the metabolism and excretion of many drugs decrease (Ruscin & Linnebar, 2018). Sex hormones also influence the absorption, metabolism, pharmacodynamics, and adverse effects of medications (Gooren & T'Sjoen, 2018). Nurses may need to take additional precautions to monitor for adverse effects and toxicity of certain medications when working with people who are transgender and taking exogenous sex hormones. The other two considerations are cardiovascular disease and bone health. In transgender women, estrogen increases the risk of cardiovascular morbidity and mortality. Additional preventive screening is warranted in these patients and lowering the dose of estrogen in transgender women over the age of 55 should be considered. Lastly, cross-sex hormone treatment can decrease bone health in both transgender women and men (Gooren & T'Sjoen, 2018). Findings from a pilot study suggest that despite having an increased risk for osteoporosis, transgender individuals' knowledge of their risks for osteoporosis can be poor (Sedlak, Roller, van Dulmen, et al., 2017) (see the Nursing Research Profile in Chart 54-3). To help reduce the risk of reduced bone mineral density, nurses should educate about osteoporosis risks and promote physical exercise and intake of vitamin D and calcium to people who are transgender and taking sex hormones (see Chapter 36 for further discussion of osteoporosis). Given these considerations, the risks of hormone treatment can be managed and rarely pose an absolute contraindication

SELF-AWARENESS ISSUES

Therapeutic communication is the primary vehicle that nurses use to apply the nursing process in mental health settings. The nurse's skill in therapeutic communication influences the effectiveness of many interventions. Therefore, the nurse must evaluate and improve his or her communication skills on an ongoing basis. When the nurse examines his or her personal beliefs, attitudes, and values as they relate to communication, he or she is gaining awareness of the factors influencing communication. Gaining awareness of how one communicates is the first step toward improving communication. The nurse will experience many different emotional reactions to clients, such as sadness, anger, frustration, and discomfort. The nurse must reflect on these experiences to p. 112p. 113 determine how emotional responses affect both verbal and nonverbal communication. When working with clients from different cultural or ethnic backgrounds, the nurse needs to know or find out what communication styles are comfortable for the client in terms of eye contact, touch, proximity, and so forth. The nurse can then adapt his or her communication style in ways that are beneficial to the nurse-client relationship.

Statistics in LGBTQ populations

There are many challenges to estimating the LGBTQ population in the United States. The biggest challenge is the lack of federal-level data. Historically, the U.S. government has not collected sexual orientation and gender identity data on surveys such as the census count. Consequently, researchers have had to use statistical modeling to estimate LGBTQ population sizes. The Williams Institute (2018), a prominent LGBTQ public policy organization, estimates that approximately 4.5% of the U.S. population is LGBTQ. That percentage translates into nearly 15 million people. Although that number encompasses sexual orientation and gender identity, at least 1 million people in the United States identify as transgender (Meerwijk & Sevelius, 2017). Of the 15 million people who are LGBTQ, 58% identify as female and 42% as male; it is important to note that these survey data did not include nonbinary or gender-fluid gender identity options. Like parents who are heterosexual, parents who are LGBTQ are married, unmarried and cohabiting, separated or divorced, and single. There are intact families and blended families, and children who live between households. There are at least 1.1 million people who are LGBTQ in a legal same-sex marriage, over 1.2 million people who are LGBTQ who are in an unmarried same-sex relationship, and upwards of 3.7 million children under the age of 18 with at least one parent who is LGBTQ (Family Equality Council, 2017). Given the numerous limitations to accurately counting the number of families headed by people who are LGBTQ, these numbers are likely much higher. Also, it is important to note that on June 26, 2015, the U.S. Supreme Court ruled in Obergefell v. Hodges (576 U.S.) that the Constitution guarantees same-sex couples the right to marry and have their marriages recognized by the states. In the United States, there are over 1000 statutory provisions classified in the U.S. Code that provide benefits, rights, and privileges to legally married couples. This ruling was important to protecting couples who are LGBTQ and their children, especially in the health care setting. For example, marriage allows people to make medical, legal, and financial decisions on behalf of an incapacitated spouse even when the spouse does not designate a durable power of attorney. Without legal marriage, people can be barred from visiting their partner in the hospital. Without marriage, people could not easily cover the health care needs of their entire family with health insurance.

Male-to-Female Gender Reassignment Surgeries

There are numerous different gender reassignment surgeries for transgender women (see Table 54-4). Over the years, researchers have identified common differences between male and female faces. Typically, the female face is oval and heart-shaped with smooth lines, pointed chin, less pronounced mandibular angles, less nasal prominence, and less angular nasal tip (Colebunders, Verhaeghe, et al., 2016). For people who desire a more feminine face, surgeries are available to modify most structures in the face. Chondrolaryngoplasty, reducing the prominent thyroid cartilage, commonly referred to as the Adam's apple, and feminizing the voice are commonly desired changes in people who are male-to-female transgender; both surgeries can be performed during the same procedure. Feminizing the voice involves shortening the vocal cord length or increasing the vocal cord tension For most transgender women, breast augmentation greatly increases subjective feelings of femininity. Surgeons typically recommend the person take estrogen for at least 12 months prior to the surgery to maximize breast growth and obtain better aesthetic results. Mammogenesis in transgender women receiving estrogen follows a pattern like the Tanner stages of breast development (see Breast Assessment in Chapter 52 for discussion of Tanner stages). Although there are some sexual differences in chest wall and mammary anatomy, the implantation of breast prostheses is not very different from breast augmentation in a female natal patient. The incision is typically made axillary, inframammary, or periareolar. The implant is created behind the glandular tissue or behind the pectoralis muscle (Colebunders, Verhaeghe, et al., 2016). Some transgender women choose to have genital reassignment surgery. The goal of genital reassignment surgery in transgender women is to create a perineogenital complex as feminine in appearance and function as possible and free of poorly healed areas, scars, and neuromas. To achieve this goal, two procedures are required, including an orchiectomy (removal of the testicles) and vaginoplasty. The major steps of a vaginoplasty (Fig. 54-3) include amputation of the penis, creation of the neovaginal cavity and the lining, reconstruction of a urethral meatus, and construction of the labia and clitoris (Colebunders, Verhaeghe, et al., 2016). Lining the neovaginal cavity requires either a skin flap or skin graft. The penile-scrotal skin flap, or penile inversion vaginoplasty, is the technique of choice and involves inverting the penile and scrotal skin (Ferrando, 2018). If the skin graft technique is used by the surgeon, skin tissue can be harvested from numerous different areas on the body, such as the penile or scrotal area, abdomen, intestines, or buccal mucosa. The goals of postoperative care of the patient undergoing male-to-female genital reassignment surgery are to prevent complications and infection and to ensure patency of the neovaginal cavity. After surgery, the patient typically remains in bed for five days with a vaginal dilator in place while receiving subcutaneous low-molecular-weight heparin (LMWH) (e.g., enoxaparin; see Chapter 26 for further discussion on anticoagulation medications). After the fifth day, the dilator is periodically removed and daily cleansing of the neovaginal cavity begins. The patient will typically remain in the hospital for 8 days. After discharge, the patient is educated on how to dilate and cleanse their vaginal cavity for 3 to 6 months. Once fully healed, the patient can begin having penetrative vaginal intercourse and stop using the vaginal dilator. If the patient does not engage in regular intercourse, they will need to continue using the vaginal dilator

Silence

There are two types of silence. One is simply remaining silent for long periods; the other is used to space talking between two people carrying on a conversation. There are three patterns of the latter. In Eastern cultures, there is a pause after each person speaks before the other does. The pause is thought to show respect and to allow for consideration of what has been said. Westerners—including English speakers in the United States—tend to interrupt this silence, leaving no pause between speakers; Americans tend to be uncomfortable with silence. In other cultures, such as Latin cultures, it is common for speakers to interrupt one another in conversation, causing overlap in speech. Within the culture, this indicates that the people are deeply engaged in the conversation, but it is perceived to be rude by other cultures.

gender identity

To fully understand the term gender identity, the concepts of sex and gender must be discussed first. Sex in the context of gender identity refers to the physical or biological characteristics that distinguish women and men, such as chromosomes, genitals, and hormones (Eliason & Chinn, 2018). For example, women have XX chromosomes, a uterus and ovaries, and the primary sex hormone is estrogen; whereas, men have XY chromosomes, a penis and testicles, and the primary sex hormone is testosterone. In most societies, people are assigned either the male or female sex at birth. However, some persons do not clearly have these defined binary sets of sex chromosomes or may not have clearly distinguishable genitalia. Intersex is a term used for a person who is born with biological traits that do not fit into those that traditionally characterize either male or female. Gender is a set of socially constructed characteristics of women and men (World Health Organization, 2019). Although a person is either assigned as male or female at birth based on sex characteristics, they are taught norms and behaviors that are appropriate for their gender. Gender is usually the first thing we notice about a person based on cues, such as voice, communication style, hairstyle, clothing, and mannerisms. Gender norms, behaviors, and cues vary from society to society and can be changed. Gender identity refers to how a person feels about themselves or their self-concept as female or male, feminine or masculine, or as something on the continuum between the two extremes (Eliason & Chinn, 2018). Cisgender is a term that often refers to people who identify with the gender that matches the sex assigned to them at birth (e.g., a person with a female sex that identifies as a woman). Transgender is an umbrella term used to describe the full range of people whose gender identity does not match with the sex assigned to them at birth. Although there is a diversity of terms that transgender people may use to identify their gender (e.g., trans, gender nonconforming, agender, and genderqueer), this chapter will use two main terms: transgender woman and transgender man. Transgender woman, or male to female, refers to a person who was assigned a male sex at birth but identifies with a female or feminine gender. Transgender man, or female to male, refers to a person who was assigned a female sex at birth but identifies with a male or masculine gender. It is important to remember that gender identity and sexual orientation are two different self-concepts. Sexual orientation refers to a person's attraction, and gender identity refers to how a person feels about their gender. For example, a transgender man who is attracted only to men has a male gender identity and a gay sexual orientation. Health care professionals should never assume a person's sexual orientation or gender identity based on physical characteristics, mannerisms, communication style, voice, clothing, or hairstyle.

The main purposes of assessing culture in a health care setting are:

To learn about the client's beliefs and usual behaviors associated with health and illness, including beliefs about disease causes, caregiving, expected treatments (both Western medicine and folk practices), daily hygiene, food preferences and rituals, religious beliefs relative to health care To compare and contrast the client's beliefs and practices to standard Western health care To compare the client's beliefs and practices with those of other persons from a similar cultural background (to avoid stereotyping) To assess the client's health relative to diseases prevalent in the specific cultural group Cultural assessment can mean adding elements of cultural assessment to the health assessment, or it can mean completing an entire cultural assessment. To know when to include cultural components—and which elements—in a health assessment, the nurse has to know how to complete an entire cultural assessment. Many of these cultural variation categories are covered in transcultural nursing and cultural anthropology texts, or can be found on the Internet. The more common cultural and biologic variations encountered in the clinical setting are described in this chapter. Knowledge of the possibilities for variation allows the nurse to select those that are most important for assessing each client. Cultural beliefs and values to assess include: Value orientation (principles of what values and behaviors are considered right or wrong by a group or an individual) Beliefs about human nature Beliefs about relationship with nature Beliefs about purpose of life Beliefs about health, illness, and healing Beliefs about what causes disease Beliefs about health Beliefs about who serves in the role of healer or what practices bring about healing Beliefs about the meaning of suffering and pain These values and beliefs can be divided into two categories: those that affect the client's approach to the health care system and provider, and those that affect the client's disease, illness, or health state. Of course there is some overlap between them. Assessing these beliefs will help the nurse to understand the client's approach to health care providers and to illness and healing. For instance, an individual who believes that diseases are punishment from God or gods may not seek help quickly or even at all. An individual who believes that evil spirits cause disease will seek out someone who can cast out evil spirits as a cure. An individual who believes that health is something that can be improved with exercise, eating the right foods, and other "healthy" behaviors will most likely seek health care for early symptoms. If a group's cultural healers play an important role, individuals belonging to that group may not accept Western-style health care without the involvement of the healer as well.

Nurse's Role in Working with Clients of Various Cultures

To provide culturally competent care, the nurse must find out as much as possible about a client's cultural values, beliefs, and health practices. Often, the client is the best source for that information, so the nurse must ask the client what is important to him or her—for instance, "How would you like to be cared for?" or "What do you expect (or want) me to do for you?" (Andrews & Boyle, 2015). At the initial meeting, the nurse must be alert for the client's preferences for greeting, eye contact, and physical distance. Based on the client's behavior, the nurse can decide what approach is best. For example, if a client offers the nurse his or her hand, the nurse should return the handshake. If the client does not offer a hand, the nurse should refrain from initiating a handshake. Variation among members of any cultural group is wide, and the nurse must remain alert for these individual differences. A client's health practices and religious beliefs are other important areas to assess. The nurse can ask, "Do you follow any dietary preferences or restrictions?" and "How can I assist you in practicing your religious or spiritual beliefs?" The nurse can also gain an understanding of the client's health and illness beliefs by asking, "How do you think this health problem came about?" and "What kinds of remedies have you tried at home?" The nurse must always ask the client and/or family about cultural beliefs and practices. Assuming a patient prefers what is known to be "usual" in his or her culture can be an error and lead to misunderstanding. This is also true concerning the dominant culture of the area or the nurse's own culture. It is never a good idea to make assumptions about another person's ideas, beliefs, and practices. The nurse will demonstrate respect for the person by asking. An open and objective approach to the client is essential. Clients will be more likely to share personal and cultural information if the nurse is genuinely interested in knowing and does not appear skeptical or judgmental. The nurse should ask these same questions even to clients from his or her own cultural background. Again, people in a cultural group vary widely, so the nurse should not assume that he or she knows what a client believes or practices just because the nurse shares the same culture.

Touch

Touch is very culturally based. How much touch is comfortable and allowable, and by whom, are all based on culture. The most modest and conservative cultures usually have religious rules about this. Touch of females by males in many of these cultures is restricted to male family members and may also be restricted among them. Even male physicians are not allowed to treat a female patient. In some religions, there are prohibitions on touching people considered to be unclean. There are prohibitions about touching parts of the body, especially the head, or touching children in some cultures because touch is a way to "give the evil eye" to another. In light of these cultural variations, a health care provider should always ask permission before touching anyone.

Balance of Hot and Cold

Two areas that are significantly different from Western culture involve beliefs about the balance of hot and cold and confinement after childbirth. Vietnamese women view the postpartum period as a cold state (duong) and protect themselves with warmth. Cultural practices include warm water for hygiene and stimulation of lactation, consuming warm foods, and staying indoors. In the United States, childbearing and recovery are viewed as healthy states, and mothers receive little formal support for both their recovery and infant care. In China, childbearing and postpartum are viewed as states that disturb the normal health balance between yin and yang. In order to restore balance in health, postpartum women engage in practices for a month related to the maternal role, physical activity, maintenance of body warmth, and certain food consumption that will restore balance. Recent research findings in a small sample of Chinese women found that postpartum confinement negatively correlates with aerobic endurance and positively correlated with depression. These findings may challenge the assumption that practices of confinement are healthy for Chinese women's recovery after childbirth (Withers et al., 2018). Many cultures believe good health requires the balancing of hot and cold substances. Because childbirth involves the loss of blood, which is considered hot, the postpartum period is considered cold, so the mother must balance that with the intake of hot food. Foods consumed should be hot in nature, and cold foods, such as fruits and vegetables, avoided. Western practices frequently use cold packs or sitz baths to reduce perineal swelling and discomfort. These practices are not acceptable to women of many cultures and can be viewed as harmful. Hot-cold beliefs are present in Latin American, African, and Asian cultures

Musculoskeletal system

Up to 90% of bone mass density (BMD) peaks around 18 in females and by age 20 in males (NIH ORBD-NRC, 2015b). Bone mass in women remains stable until after menopause, when it begins to decrease. Bone mass decreases in both sexes with age and some specific conditions, including lack of weight-bearing exercise. BMD is higher in men and African Americans and lowest in Asians. However, bone fracture patterns appear to be less related to bone density and size than to differences in calcium metabolism, as influenced by calcium and sodium intake, although the relative importance of calcium and sodium in calcium metabolism has not yet been determined among Asians (Walker et al., 2008). Ethnic variation in arthritis in the United States indicates that African Americans and Caucasians have similar rates, while Hispanics have lower rates diagnosed by physicians, but higher incidence of work-related limitations and severe joint pain on diagnosis (CDC, 2005, 2011). Regarding rheumatoid arthritis, African Americans have a lower genetic predisposition (10% carry the genetic marker) compared with Caucasians (25%; The Scripps Research Institute, n.d.).

Blood Products, Transfusions, and Organ Donations

Use of blood products and blood transfusions is accepted by most religions except for Jehovah's Witnesses. Organ donation and autopsy are not accepted by certain cultural groups, including Christian Scientists, Orthodox Jews, Greeks, and some Spanish-speaking groups (because of the belief that the person will suffer in the afterlife if organs are removed or autopsy is done). African Americans (12.6% of the population) donate at a low level but make up a substantial portion of the need for donated organs (Bratton et al., 2011). Bratton et al. (2011) have listed barriers to minority donation from both deceased and living donors. Barriers from deceased donors:Lack of awareness of transplantationReligious or cultural distrust of the medical communityFear of medical abandonment (if donating)Fear of racism Barriers from living donors:Unwillingness to donateMedical comorbid conditionsDistrust or fear of medical communityLoss to follow-up (not returning for follow-up appointments)Poor coping mechanismsFinancial concernsReluctance to ask family members and friendsFear of surgeryLack of awareness about living donor kidney transplantation

Guided imagery

Use of consciously chosen positive and healing images along with deep relaxation to reduce stress and to help people cope

Reflexology

Use of deep massage on identified points of the foot or hand to scan and rebalance body parts that correspond with each point

Aromatherapy

Use of essential oils to stimulate the sense of smell for balancing mind, body, and spirit

Valerian (Valeriana officinalis)

Used as a sleep aid May prolong the effects of some types of anesthesia

St. John's wort (Hypericum perforatum)

Used to decrease anxiety, help with depression and sleep problems May prolong the effects of anesthesia

Ginkgo biloba

Used to improve memory Can increase bleeding

Ginseng

Used to increase concentration Can increase HR and risk of bleeding

Physical Distance or Space

Various cultures have different perspectives on what is considered a comfortable physical distance from another person during communication. For some people, 2 to 3 ft is a comfortable distance while others tend to stand closer to one another. And yet others are more comfortable with distances greater than 2 or 3 ft. The nurse should be conscious of these cultural differences in space and should allow enough room for clients to be comfortable

Communication

Verbal communication can be difficult when the client and nurse do not speak the same language. The nurse should be aware that nonverbal communication has different meanings in various cultures. For example, some cultures welcome touch and consider it supportive, while other cultures find touch offensive. Some people avoid shaking hands, believing that vigorous handshaking is aggressive, while others consider a firm handshake a sign of strength and good character. Although some people view direct eye contact as positive, others may find it rude and may avoid looking strangers in the eye when talking to them. Some people maintain intense eye contact, which may be perceived as glaring to others. These differences are important to note because many people make inferences about a person's behavior based on the frequency or duration of eye contact. Chapter 6 provides a detailed discussion of communication techniques.

Veterans Considerations

Veterans of the U.S. armed services comprise a unique population with health care needs that vary dependent upon branch of military service, whether service occurred during wartime eras, time and place of service, and individual experiences (Olenick, Flowers, & Diaz, 2015). According to the U.S. Census Bureau (2019), there are currently 18 million veterans, 1.8 million of whom are female. Substance use disorders (SUDs), posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), suicide, depression, hazardous substance exposure, and amputations are common health care problems found among veterans (Olenick et al., 2015) (see Chapter 4). According to a Pew Research Center (2017) report, the proportion of Americans who served in the U.S. military has been steadily declining since 1980, when 18% of American adults were veterans. In 2016, 7% of Americans were veterans. That proportion is projected to continue to decline, and by 2045 the U.S. Department of Veteran Affairs estimates that there will be approximately 12 million veterans, roughly a 40% decrease from 2016

Eyes

Visual impairment varies across age (greater after 50), gender (more in females), and geography (more than 90% live in developing countries) (WHO, 2016b). In all but highly developed countries, cataract is the leading cause of visual disease and blindness, followed by glaucoma and age-related macular degeneration (which is the leading cause in developed countries). Other diseases include trachoma, other corneal diseases, diabetic retinopathy, and diseases of children, such as cataract, prematurity retinopathy, and vitamin A deficiency (WHO, 2016a).

Causes of Illness

Western health care and medicine use the biomedical model as a basis for defining illness and treatments. This model is based on what science can investigate and conclude and assumes that all disease or illness has a cause and effect that can be studied. Even the usual approach of body-mind-spirit has been based on a perspective that the interaction of these components can be measured. Only recently has there been the introduction of a nonmaterialistic, nonmechanical additional perspective that allows for psychological and spiritual components in the disease process. The origin of this addition to Western medicine comes from Asian medicine beliefs. Other beliefs about disease and illness causation, often based on Asian or indigenous populations' (such as Native Americans) beliefs, are categorized as holistic (or naturalistic) and magicoreligious (Fig. 11-5). In naturalistic belief systems, the focus is on keeping harmony or natural balance in the cosmic natural order, in which human life is only one aspect. Well-known theories associated with this belief system are the yin/yang theory of China (Eastern or Chinese medicine), and the hot/cold theory found in many other cultures that were influenced by the Greek philosopher Galen, who transmitted India-based beliefs to much of the world influenced by Greek culture. The hot/cold theory has holistic aspects, as it is based on a concept of whole person versus sum of the parts, and seeks a balance of all aspects of a person. There are perceived to be four "humors" of the body (blood, phlegm, black bile, and yellow bile) that work together to regulate the bodily functions. Balance is maintained by adding or subtracting substances that regulate the body's temperature, moisture, and dryness. Diet and medications are thought to have varying characteristics of hot/cold and wet/dry, and interact with diseases that are thought to be hot or cold. In the magicoreligious belief system, the entire universe is seen to have supernatural forces at work, which affect all humans as well as the world in general. Spirits and various other entities are thought to affect the status of both physical and mental health.

Diet and Nutrition

What we eat, how we eat it, and even when we eat are all culturally based. Dietary considerations in cultural assessment include the meaning of food to the individual, common foods eaten and rituals surrounding the eating, the distribution of food throughout a 24-hour day, religious beliefs about foods, beliefs about food and health promotion, and nutritional deficiencies associated with the ethnic group. If possible, compare the nutrients of foods not usual in the United States with nutrition charts to understand how healthy a diet is, especially with regard to diseases such as diabetes mellitus. It is very difficult to get a client to change habitual dietary habits drastically, even with knowledge of the interaction of diet and disease. What food means to the individual can also be very important. It may serve as a comfort, as a means to stay close to ethnic roots or family. Providing food may be considered to reflect caring and love, while withdrawing food may be considered akin to torture. When meals are served can seriously affect appetite. For those who usually eat a midday meal at 2:00 or 3:00 PM, it is unappetizing to see lunch served at 11:00 AM or 12 noon, and a 5:00 or 6:00 PM dinner is considered a late lunch rather than an evening meal. Religious beliefs affect what can and cannot be eaten, such as the prohibition of pork or pork products for Jews and Muslims and religious practices of fasting. Asking about specific diet requirements or preferences is part of cultural assessment. For dietary and nutrition practices related to religious beliefs, see Chapter 12.

eye contact

a culturally determined behavior. Although most nurses have been taught to maintain eye contact when speaking with patients, some people from certain cultural backgrounds may interpret this behavior differently. For example, some Asians, Native Americans, Indo-Chinese, Arabs, and Appalachians may consider direct eye contact impolite or aggressive, and they may avert their own eyes when talking with nurses and others whom they perceive to be in positions of authority. Some Native Americans stare at the floor during conversations—a cultural behavior conveying respect and indicating that the listener is paying close attention to the speaker. Some Hispanic patients maintain downcast eyes as a sign of culturally appropriate deferential behavior toward others on the basis of age, gender, social position, economic status, and position of authority (Giger, 2016). Eye contact is an important tool in a transcultural assessment and is used for both observation and to initiate interaction (Giger, 2016). The nurse who is aware that eye contact may be culturally determined can better understand the patient's behavior and provide an atmosphere in which the patient can feel comfortable.

erogenous zones:

areas of the body that produce sexual desire and arousal when stimulated

An intersex condition occurs

in about 1 in every 2,000 babies, in which there are contradictions among chromosomal sex, gonadal sex, internal organs, and external genital appearance, resulting in ambiguous gender. However, this statistic is evolving, just like the definition and classification of intersex as a disorder of sex development (DSD; Intersex Society of North America, n.d.; Safer, 2017). Congenital adrenal hyperplasia (CAH) is one of the most well-known causes of ambiguous genitalia (Safer, 2017). Management of a child born intersex raises questions regarding the historically supported intervention of immediate surgery to create either male or female external genitalia. There is some evidence in the literature from studies of patients with DSD and neuroanatomical studies that support the biological nature of gender identity (Saraswat, Weinand, & Safer, 2015). This raises the question of when decisions should be made and who should be involved in the decision-making regarding sex assignment: Should the parents make the decision based on advice from the provider, or should the decision be postponed until the child is old enough to participate? More research needs to be done in this area to assist parents and providers in the decision-making required in these cases.

Nursing dx

ineffective sexuality pattern and sexual dysfunction

Transgender, frequently shortened to trans,

is a term that describes a wide range of experiences or identities where gender identification and expression differ from societal expectations that are based on a person's biological sex. For example, a person born biologically male (penis and scrotum) may identify as female (gender). More specifically, transgender is an inclusive term used to describe those who feel that the sex that was assigned to them at birth incompletely describes or fails to describe them. This term includes: People who have a gender expression that differs from their biological sex (according to societal norms) People who are transsexual—that is, people who live full-time as members of a gender that differs from the sex and gender they were assigned at birth People who are intersex—that is, people whose reproductive or sexual anatomy does not fit the typical definition of male or female People who identify outside the female/male binary People who identify as having no gender or multiple genders For many transgendered people, the solution is to change their bodies, through surgery, hormone therapy, or both, to match their inner feelings; this process is referred to as transitioning. The surgery is frequently referred to as gender affirmation surgery or gender confirmation surgery. The terminology used for the surgery is significant: It reinforces the belief that the surgery is realigning a person with their actual gender. Teens who are transgender face the reality of puberty, where their body will go through biological changes that betray who they feel they are or who they want to be. Puberty blockers, medications that pause puberty, may be taken to block secondary sex characteristics for a few years. They are generally safe, and their effects are reversible. Exogenous hormones (testosterone or estrogen) may also be administered. When the teen reaches the age of consent and has solidified his or her gender identification, surgery may be a viable, even medically necessary option (WPATH, 2016). Typically, genital surgery requires two mental health evaluations to confirm gender dysphoria, capacity for informed consent, 12 continuous months of hormone use, control of significant medical or mental health concerns, and living in the gender to which a person is transitioning

To complete a culturally competent assessment,

it is essential to interact with the client showing respect for the person, the family, and beliefs. Challenge yourself to learn about many of the cultural groups in your geographical area and interact with them enough to gain some understanding and appreciation for their worldviews (Fig. 11-1). Use your knowledge when meeting and assessing your clients, but be alert for behaviors, descriptions, or physical variations that need to be clarified as normal for their culture or abnormal and needing further assessment.

Abstinence

not having sex. It is the most effective form of birth control, preventing pregnancy 100% of the time when practiced consistently. Abstinence also prevents the transmission of STIs 100% of the time when practiced appropriately and consistently. Some STIs spread through oral-genital sex, anal sex, or even intimate skin-to-skin contact without actual penetration (genital warts and herpes can be spread this way). Therefore, only avoiding all types of intimate genital contact can prevent these STIs. Avoiding all types of intimate genital contact—including anal and oral sex—is complete abstinence. There are no side effects or health risks related to abstinence.

transgender man

refers to a person who was assigned a female sex at birth but identifies with a male or masculine gender

transgender woman

refers to a person who was assigned a male sex at birth but identifies with a female or feminine gender

Cultural Assessment

refers to a systematic appraisal or examination of individuals, families, groups, and communities in terms of their cultural beliefs, values, and practices. Nurses need to ensure that patients of all cultures understand what the nurse is trying to accomplish by gathering cultural data during the assessment process in order to avoid misunderstanding (Holland, 2018). In an effort to establish a database for determining a patient's cultural background, nurses have developed cultural assessment tools or modified existing assessment tools (Leininger, 2002) to ensure that transcultural considerations are included in the plan of care. Giger and Davidhizar's Transcultural Assessment Model can be used to help nurses perform cultural assessments. Questions derived from this model may be used to direct nursing assessment of a person's ethnic, cultural, or religious beliefs and its relationship to their personal and health care traditions (Chart 4-7) (Giger, 2016). In addition, nurses should gather data on patients' cultural perceptions and family ancestry throughout the assessment process. Nurses should recognize that advancing knowledge about culturally congruent care is important for promoting care that is consistent with the cultural needs of each patient's heritage

Social organization

refers to family structure and organization, religious values and beliefs, ethnicity, and culture, all of which affect a person's role and therefore his or her health and illness behavior. Some people may seek the advice of a friend or a family member or may make most decisions independently. Many people strongly value the role of family in making health care decisions and may delay making decisions until they can consult appropriate family members. Autonomy in health care decisions is often an unfamiliar and undesirable concept because the focus is the collective rather than the individual.

abstinence

refraining from having sex

Sexual orientation refers to

romantic, emotional, affectionate, or sexual attraction to other people

Voyeurism:

the achievement of sexual arousal by looking at the body of someone other than one's sexual partner. Although voyeurism itself is not inherently wrong, some voyeurs develop complex means to spy on others that involve violations of privacy that are illegal.

Anal intercourse

the act of inserting the penis into the anus and rectum of a partner, is another form of intercourse. Commonly practiced by gay men, it is also used by heterosexual couples. Once the penis (or any object) is placed in the rectum, it should not be introduced into the vagina without thorough cleansing because many microorganisms present in the rectum can cause vaginal infections. Care should be used to avoid injury to the delicate rectal mucosa, and lubrication is essential for comfort. Condoms are now recommended for both vaginal and anal intercourse to prevent sexually transmitted infections (STIs).

Gender role behavior is

the behavior a person exhibits in relation to being male or female, which, again, may or may not be the same as biological sex or gender identity.

Gender identity is

the inner sense a person has of being male or female (or other), which may be the same as or different from that person's biological sex.

gender identity

the internal self-conception of one's gender

Touch

the most personal of all sensations, is central to the human communication process, and is often used as a method of communication (Giger, 2016). The meaning that people associate with touching is culturally determined to a great degree. In some cultures (e.g., Hispanic, Arab), male health care providers may be prohibited from touching or examining certain parts of the female body. Similarly, it may be inappropriate for females to care for males. Among many Asians, it is impolite to touch a person's head because the spirit is believed to reside there. Therefore, assessment of the head or evaluation of a head injury requires permission of the patient or a family member, if the patient is not able to give permission. The patient's culturally defined sense of modesty must also be considered when providing nursing care. For example, some Jewish and Muslim women believe that modesty requires covering their head, arms, and legs with clothing. It is important for the nurse to recognize cultural variances and to understand that touch can be perceived as intrusive to some patients.

Pedophilia:

the practice of adults gaining sexual fulfillment by performing sexual acts with children. Unlike the other items on this list that (depending on the circumstances) may be considered adaptive sexual responses, pedophilia involves children who, by nature of their age and maturity, cannot consent to sexual activity. Pedophilia is wrong, illegal, and maladaptive in all cases.

Sadism:

the practice of gaining sexual pleasure while inflicting abuse on another person

People who are LGBTQ (lesbian, gay, bisexual, transgender, and queer) have

unique health care needs. They also experience particular health risks and disparities based on sexuality and gender identity. Increasingly, nursing and medical professionals are recognizing these risks and disparities; furthermore, these professionals are acknowledging the importance of providing culturally appropriate care to people who identify as LGBTQ. Nurses will encounter people who are LGBTQ and their families in every practice setting. As they would for other diverse populations, nurses should be prepared to provide quality and culturally appropriate care. This chapter focuses on the terminology around sexuality and gender identity, culturally appropriate assessment and communication, and assessment and management of patients who identify as LGBTQ, and, in particular, the unique health care needs of those patients seeking gender reassignment. The management of patients seeking gender reassignment using both nonsurgical and surgical treatments is discussed.

sexual harassment:

unwelcome verbal or physical advance or sexually explicit statement (e.g., leers, pats, grabs, jokes, requests for dates, and even rape) that interferes with one's ability to do one's job by making one feel humiliated, intimidated, or uncomfortable

Time orientation

whether one views time as precise or approximate, differs among cultures. Many countries focus on the urgency of time, valuing punctuality, and precise schedules. Clients from other countries or cultures may not perceive the importance of adhering to specific follow-up appointments or procedures or time-related treatment regimens. Health care providers can become resentful and angry when clients miss appointments or fail to follow specific treatment regimens such as taking medications at prescribed times. Nurses should not label such clients as noncompliant when their behavior may be related to a different cultural orientation to the meaning of time. When possible, the nurse should be sensitive to the client's time orientation, as with follow-up appointments. When timing is essential, as with some medications, the nurse should explain the importance of more precise timing.

Gender fluid describes a person

whose gender identification and behaviors shift from time to time, whether within or outside of societal, gender-based expectations. There is an emerging understanding that external genitalia do not always dictate gender identification or gender expression. Some people identify as nonbinary, and may prefer the gender-neutral pronouns they and their rather than him/her or his/her. Each person's experience is individual, and the vocabulary and terms continue to evolve. There is a growing understanding that asking people what their preferred pronouns are is appropriate.

Specific Learning Principles Related to Parents

• Adults are self-directed. Adults value independence and want to learn on their own terms. Teaching strategies that include such concepts as role playing, demonstration, and self-evaluation are most helpful. Using this model, nurses can partner with families to ensure that education is interactive and adopt the role of facilitator rather than lecturer. • Adults are problem-focused and task-oriented. Adults learn best when they perceive there is a gap in their knowledge base and want information and skills to fill the gap. Providing a reason to learn can often motivate families that appear slow to comply with their child's care and education. • Adults are goal-oriented. Adults learn best at a time when learning meets an immediate need. Presenting information in an organized, sequential, and timely fashion can often help families understand the importance of learning a particular piece of information or task. • Adults value past experiences and beliefs. Adults bring an accumulated wealth of experiences to each health care encounter; this provides a rich base for new learning. Education should take into account a wide range of backgrounds. Appreciating and using individual differences during teaching encounters can help improve compliance and reduce resistance to educational goals.

Adolescent Sexuality

• It should be your choice to engage in sexual relations. Do not be influenced by peers. When you say "no," be firm and clear about your position. • Pregnancy, sexually transmitted infections, and HIV infection can occur with any sexual encounter without the use of barrier methods of contraception. Use appropriate contraception if sexually active. Discuss abstinence as a contraceptive method. • Sexual activity in a mature relationship should be pleasurable to both parties. If your sexual partner is not interested in your pleasure, you need to reconsider the relationship.

Communicating Effectively About Nutrition With Culturally Diverse Patients

Acquire basic information about health beliefs and practices of various cultural groups in your health care setting. This provides a basis for assessing patients' beliefs and practices. Recognize, however, that within all cultures and ethnic groups, there are members who do not hold all the values of the group. Ask specifically about the use of folk or home remedies prescribed by a nontraditional healer. Determine the patient's language preferences for spoken and written communication. Utilize printed or audiovisual information that is in the language spoken by your patients. Promote healthy food choices by identifying healthy traditional food practices and encourage their use. Encourage cultural sensitivity in health care workers in your particular setting. Recognize that diversity exists within cultural groups. For example, the Hispanic population includes Mexicans, Cubans, Puerto Ricans, and other Latino groups. Emphasize threads or messages in health teaching that are common to all cultures (e.g., concern about family, faith, home). Help culturally diverse patients to value and understand the importance of communicating concerns and asking questions about prescribed dietary practices.

Megadoses of Nutrient Supplements

Because some nutrients compete against each other for absorption, an excess of one nutrient can lead to a deficiency (or increase the requirement) of another, especially if one is absorbed preferentially. For instance, a delicate balance exists between zinc and copper. People who take therapeutic levels of zinc run the risk of developing a copper deficiency—which is otherwise rare—unless they also increase their intake of copper. Dietary supplements can have drug-like effects and may interact with food and medication (Karch, 2017). Accurate information regarding the patient's use of dietary supplements is imperative to provide safe and appropriate care. The use of herbs, vitamins, minerals, and other supplements can impact a patient's plan of care and must be considered by all members of the health care team. For example, a patient taking ginkgo biloba (an herbal) and aspirin may have to have surgery postponed due to an increased risk for excessive bleeding, because each of these substances have anticoagulant properties. A list of accurate, reliable sources for the latest information about specific herbs and supplements based on scientific evidence is included in the Internet Resources found on website.

Develop Cultural Self-Awareness

Before you can provide culturally competent care to patients from diverse backgrounds, you'll need to become aware of the role of cultural influences in your own life. Objectively examine your own beliefs, values, practices, and family experiences. As you become more sensitive to the importance of these factors, you'll also become more sensitive to cultural influences in others' lives. Identify your biases. How do they affect your feelings about others? How could they affect your nursing care of others?

Common Responses to Pain

Behavioral (Voluntary) Responses Moving away from painful stimuli Grimacing, moaning, and crying Restlessness Protecting the painful area and refusing to move Physiologic (Involuntary) Responses Typical Sympathetic Responses When Pain is Moderate and Superficial Increased blood pressurea Increased pulse and respiratory ratesa Pupil dilation Muscle tension and rigidity Pallor (peripheral vasoconstriction) Increased adrenaline output Increased blood glucose Typical Parasympathetic Responses When Pain is Severe and Deep Nausea and vomiting Fainting or unconsciousness Decreased blood pressure Decreased pulse rate Prostration Rapid and irregular breathing Affective (Psychological) Responses Exaggerated weeping and restlessness Withdrawal Stoicism Anxiety Depression Fear Anger Anorexia Fatigue Hopelessness Powerlessness

Eastern European Jews

Cystic fibrosis Gaucher's disease Spinal muscular atrophy Tay-Sachs' disease

Hispanics

Diabetes mellitus Lactose intolerance

Physical, Sociocultural, and Psychosocial Factors That Influence Food Choices

Dietary choices or restrictions also are influenced by economics, culture, religion, and personal feelings and meanings associated with food. The financial income of the patient or the patient's household can directly impact the ability to purchase sufficient food and/or food of high nutritional value. Diverse lifestyles and eating habits directly impact a person's nutritional health and well-being. Religious restrictions and beliefs or cultural practices may affect the patient's acceptance of, response to, and compliance with dietary therapies. Health care providers need an understanding of a patient's cultural values, beliefs, and practices to provide culturally acceptable care.

Among the elements of cultural competence (Purnell, 2014) are the following:

Developing an awareness of one's own existence, sensations, thoughts, and environment to prevent them from having an undue influence on those from other backgrounds Demonstrating knowledge and understanding of the patient's culture, health-related needs, and culturally specific meanings of health and illness Accepting and respecting cultural differences in a manner that facilitates the patient's and family's abilities to make decisions to meet their needs and beliefs Not assuming that the health care provider's beliefs and values are the same as the patient's Resisting judgmental attitudes such as "different is not as good" Being open to and comfortable with cultural encounters Accepting responsibility for one's own education in cultural competence by attending conferences, reading professional literature, and observing cultural practices These elements suggest that becoming culturally competent is a life-long challenge, and that nurses should strive to be culturally humble—recognizing what we don't yet know about those entrusted to our care and being willing to learn what we need to know. The Office of Minority Health of the U.S. Department of Human Services created "Think Cultural Health" (https://www.thinkculturalhealth.hhs.gov), an online service whose goal is to advance health equity at every point of contact through the development and promotion of culturally and linguistically appropriate services. Nurses who recognize and respect cultural diversity are better equipped to exhibit cultural sensitivity and provide nursing care that accepts the significance of cultural factors in health and illness. See Box 5-1 for other helpful web resources. The health care system is itself a culture with customs, rules, values, and a language of its own, with nursing as its largest subculture. As you progress through your education, you will be acculturated into the culture of the health care system and will develop values related to health and health care. Box 5-2 (on page 90) lists some common cultural norms of the health care system.

female genital mutilation (FGM):

any procedure that involves partial or total removal of the external female genitalia or other injury to the female genital organs for nonmedical reasons

Biological Sex Roles

In some cultures, the man is the dominant figure and generally makes decisions for all family members. For example, if approval for medical care is needed, the man may give it regardless of which family member is involved. In male-dominant cultures, women are often passive. On the other hand, there are cultures in which women are dominant. Knowing who is dominant in the family is important when planning nursing care. For example, if the dominant member is ill and can no longer make decisions, the whole family may be anxious and confused. If a nondominant family member is ill, the person may need help in verbalizing needs, particularly if the needs differ from those the dominant member perceives as being important.

Nursing care for a patient in pain is always individualized, but important culture-sensitive considerations include the following:

Recognize that culture is an important component of individuality, and that each person holds (and has the right to hold) various beliefs about pain. Respect the patient's right to respond to pain in his or her own manner. Never stereotype a patient's perceptions of or responses to pain based on the person's culture.

impotence:

condition in which a man is unable to attain or maintain an erection to such an extent that he cannot have satisfactory sexual intercourse; synonym for erectile failure

bisexual:

having sexual feelings for people of both sexes

Myths and Realities About Older Adults

ld age begins at 65 years of age. Defining 65 years of age as old age happened arbitrarily when 65 years of age was set for Social Security payments in the 1930s, based on the labor market and the economy of that time. Most older adults live in long-term care facilities. Although the largest percentage of residents in long-term care facilities are older adults, many of whom have disabilities, only about 3% of older adults live in long-term care facilities (West et al., 2014). Most older adults are sick. As of 2015, 80% of older adults aged 65-74 and 68% of older adults over age 85 rate their health good, very good, or excellent (Federal Interagency Forum on Aging-Related Statistics, 2016). Old age means mental deterioration. Although response time may be prolonged due to a longer processing time, neither intelligence nor personality normally decrease because of aging. Older adults are not interested in sex. Although sexual activity may be less frequent, the ability to perform and enjoy sexual activity lasts well into the 90s in healthy older adults. Older adults don't care how they look. Older adults want to be attractive to others. Most older adults are isolated and lonely. Loneliness results from death of loved ones or other losses, just as it does for people of all ages. Many older adults participate in social and community activities. Bladder problems are a problem of aging. Incontinence is not a part of aging; it generally has a root cause and requires medical attention. Older adults do not deserve aggressive treatment for serious illnesses. Older adults deserve aggressive treatment if they want it. Older adults cannot learn new things. Many older adults today are more educated than previous generations, and have had to adapt to technologic advances; they continue to use technology into old age.

Transcultural nursing

now both a specialty and a formal area of practice, originated from work by Dr. Leininger (1991), a nurse-anthropologist. Her Theory of Cultural Care Diversity and Universality provides the foundation for providing culturally respectful care for patients of all ages, as well as families, groups, and communities. A nurse who is culturally respectful has the knowledge and skills to adapt nursing care to cultural similarities and differences. Cultural competence takes time. It involves developing awareness, acquiring knowledge, and practicing skills. Each patient must be considered a unique person. What is true of one person may not be true of another, even if they are from the same cultural background.

contraception:

prevention of conception or pregnancy; also used to describe methods used for birth control

transcultural nursing:

providing nursing care that is planned and implemented in a way that is sensitive to the needs of individuals, families, and groups representing the diverse cultural populations within our society

A person's cultural beliefs and practices can influence

rest and sleep. Although developmental stages are similar, children's bedtime rituals, sleeping position and place, and pattern of sleep may vary based on culture. Methods to enhance or foster sleep may also be culturally influenced. A cultural orientation toward privacy and quiet makes sleep difficult in a busy special care unit. Sensitivity to a patient's culture must be included in the plan of care for preparing the patient for an evening's sleep.

ethnicity:

sense of identification that a cultural group collectively has; the sharing of common and unique cultural and social beliefs and behavior patterns, including language and dialect, religious practices, literature, folklore, music, political interests, food preferences, and employment patterns a sense of identification with a collective cultural group, largely based on the group members' common heritage. One belongs to a specific ethnic group or groups either through birth or through adoption of characteristics of that group. People within an ethnic group generally share unique cultural and social beliefs and behavior patterns, including language and dialect, religious practices, literature, folklore, music, political interests, food preferences, and employment patterns. Ethnicity largely develops through day-to-day life with family and friends within the community.

Nursing care can become complicated when

the patient and the nurse have distinctly different cultural norms. Cultural imposition in health care is the tendency for health personnel to impose their beliefs, practices, and values on people of other cultures. Closely related to cultural imposition is ethnocentrism, the belief that the ideas, beliefs, and practices of one's own culture are superior to those of another's culture. When health professionals assume that they have the right to make choices and decisions for patients of another culture, patients may respond in the same way that minority cultures often respond to such an attitude by the dominant culture: by becoming passive, resistive, angry, or resistant to treatment. Unless nurses are willing to examine carefully and clarify their own attitudes and values and to be sensitive to others who are "different," their use of cultural concepts when providing care will be unsuccessful. The nurse's role is to understand the patient's needs and to adapt care to respectfully meet those needs. A careful merging of modern and traditional cultural beliefs is a necessary prerequisite for safe, considerate, and successful nursing care of all patients.

When providing care to a person from a culture that is different from your own or the dominant culture, you may

use past experiences with members of that culture as a guide but never as the answer to all cultural issues. Learn from your mistakes and do not repeat them. All nurses make mistakes at some time when caring for patients from different cultures. Inadvertent mistakes are just that, but repeated mistakes are careless and disrespectful; they will adversely affect your interaction with patients and coworkers. The following sections provide additional guidelines for providing culturally appropriate nursing care.

Anxiety and Other Stressors

which is almost always present when pain is anticipated or being experienced, tends to increase the perceived intensity of pain. The threat of the unknown is ordinarily more devastating and anxiety-producing than a threat for which one has been prepared. Many studies have focused on the relationship between anxiety and pain, or depression and pain, but the results are conflicting and unclear regarding these relationships. Until this has been confirmed, it is best to assume that pain is the underlying cause when anxiety or depression is also present (Pasero & McCaffery, 2011). Although a cause-and-effect relationship has not clearly been verified, pain may be aggravated with anxiety, muscular tension, and fatigue. The rested and relaxed person can often cope with more discomfort than someone who is suffering from a lack of sleep. A person who is greatly fatigued and who has no competing demands requiring attention may experience pain more acutely. For example, many people have discovered that the pain of a foot ache or an ingrown toenail that was only mildly annoying during the day's work becomes unbearable at night when there is nothing else to distract the mind from the pain.

Alcohol Abuse

Alcohol can alter the body's use of nutrients, and thereby its nutrient requirements, by numerous mechanisms. The toxic effect of alcohol on the intestinal mucosa interferes with normal nutrient absorption; thus, requirements increase as the efficiency of absorption decreases. Need for B vitamins increases because they are used to metabolize alcohol. Alcohol can also influence nutrient metabolism by impairing nutrient storage, increasing nutrient catabolism, and increasing nutrient excretion. Alcohol abuse that results in liver damage has profound effects on the body's nutrient metabolism and requirements.

cultural diversity:

(1) coexistence of different ethnic, biological sex, racial, and socioeconomic groups within one social unit; (2) diverse groups in society, with varying racial classifications and national origins, religious affiliations, languages, physical size, biological sex, sexual orientation, age, disability, socioeconomic status, occupational status, and geographic location defined as the coexistence of different ethnic, biological sex, racial, and socioeconomic groups within one social unit (Dictionary.com, 2014). These groups include, but are not limited to, people of varying religion, language, physical size, sexual orientation, age, disability, occupational status, and geographic location. Culture is an integral component of both health and illness because of the cultural values and beliefs that we learn in our families and communities. Nurses and other health care providers must be familiar with the concepts of cultural diversity in order to understand characteristics common to certain populations.

Reactions to Pain

Health care researchers have discovered that many of the expressions and behaviors exhibited by people in pain are culturally prescribed. Some cultures allow or even encourage the open expression of emotions related to pain, whereas other cultures encourage suppression of such emotions. You should not assume that a patient who does not complain of pain is not having pain. If you make this assumption, you may overlook the pain-reduction needs of a patient who deals with pain quietly and stoically. To avoid this error, be sensitive to nonverbal signals of discomfort, such as holding or applying pressure to the painful area, avoiding activities that intensify the pain, and uncontrollable, spontaneous expressions of discomfort, such as facial grimacing and moaning. You also should not consider patients who freely express their discomfort as constant complainers with excessive requests for pain relief. Pain is a warning from the body that something is wrong. Pain is what the patient says it is, and every complaint of pain should be assessed carefully.

Mental Health

Most mental health norms originate in research and observations made of White, middle-class people. But many ethnic groups have their own norms and acceptable patterns of behavior for psychological well-being, as well as different normal psychological reactions to certain situations. For example, many Hispanic people deal with problems within the family and consider it inappropriate to tell problems to a stranger. Some traditional Chinese people consider mental illness a stigma and seeking psychiatric help a disgrace to the family. In times of high stress or anxiety, some Puerto Ricans may demonstrate a hyperkinetic seizure-like activity known as ataques; this behavior is a culturally accepted reaction. Be aware of these variations and accept them as culturally appropriate.

CULTURAL INFLUENCES ON HEALTH AND ILLNESS

People's values and beliefs about health, illness, and health care are influenced by cultural and ethnic groups. For example, in some groups, illnesses are classified as either natural or unnatural. "Natural illnesses" are caused by dangerous agents, such as cold air or impurities in the air, water, or food. "Unnatural illnesses" are punishments for failing to follow God's rules, resulting in evil forces or witchcraft causing physical or mental health problems. In some cultures, the power to heal is thought to be a gift from God bestowed on certain people. People in these cultures believe that these folk or traditional healers know what is wrong with them through divine intervention and experience. A patient accustomed to traditional healers may think that health care providers are incompetent because they have to ask many questions before they can treat an illness. Traditional healers speak the patient's language, often are more accessible, and are usually more understanding of the patient's cultural and personal needs. People from different cultures may also have different beliefs about the best way to treat an illness or disease. For example, herbs are a common method of treatment in many cultures. In fact, many medications used today have a basis in herbs or other plant sources that have been used for centuries to cure illnesses. If a patient traditionally drinks an herbal tea to alleviate symptoms of an illness, there is no reason that both the herbal tea and prescribed medications cannot be used, as long as the tea is safe to drink and the ingredients do not interfere with or exaggerate the action of the medication. Other traditional therapies include the use of cutaneous stimulation, therapeutic touch, acupuncture, and acupressure. Cutaneous stimulation by massage, vibration, heat, cold, or nerve stimulation reduces the intensity of the sensation of pain. Therapeutic touch is an intentional act that involves an energy transfer from the healer to the patient to stimulate the patient's own healing potential. Acupuncture, long used in China, is a method of preventing, diagnosing, and treating pain and disease by inserting special needles into the body at specified locations. Acupressure involves a deep-pressure massage of appropriate points of the body. Read more about these therapies

Physiologic Variations

Studies have shown that certain racial and ethnic groups are more prone to certain diseases and conditions. For example, a hereditary disorder, Tay-Sachs' disease, is associated with people of Eastern European Jewish descent. Although the incidence of this disorder has declined over the years owing to improved and earlier testing, it is still a concern. Use knowledge of such risk factors when interviewing a patient to complete a health history.

The ESFT Model

The ESFT model guides providers in understanding a patient's explanatory model (a patient's conception of her or his illness), social and environmental factors, and fears and concerns, and also guides providers in contracting for therapeutic approaches. E—Explanatory Model of Health and Illness What do you think caused your problem? Why do you think it started when it did? How does it affect you? What worries you most? What kind of treatment do you think you should receive? S—Social and Environmental Factors How do you get your medications? Are they difficult to afford? Do you have time to pick them up? How quickly do you get them? Do you have help getting them if you need it? F—Fears and Concerns Does the medication sound okay to you? Are you concerned about the dosage? Have you heard anything about this medication? Are you worried about the adverse effects? T—Therapeutic Contracting Do you understand how to take the medication? Can you tell me how you will take it?

Health Disparities

refers to health differences between groups of people; they can affect how frequently a disease affects a group, how many people get sick, or how often the disease causes death. Many different populations are affected by disparities, including racial and ethnic minorities; residents of rural areas; women, children, and the older adult; and persons with disabilities.

Economic Factors

The adequacy of a person's food budget affects dietary choices and patterns. The increasing cost of food, coupled with limited purchasing power, may result in a decrease in the nutritional quality of the diet. Many variables influence the types of foods purchased. Creative use of the food dollar means using unit pricing to determine cost per serving (e.g., comparing the unit price of 39¢ per serving with a similar product's 45¢ per serving), selecting foods that contain adequate nutrients, and buying seasonal foods that are more economical and can be prepared easily at home. Avoiding convenience foods and meals purchased away from home can save food dollars.

Although nursing as a whole is actively recruiting more diverse members, many nurses are members of, and have the same value systems as, the dominant U.S. middle-class culture. When a nurse with a particular set of cultural values about health interacts with a patient with a different set of cultural values about health, the following factors affect this interaction (

The cultural background of each participant The expectations and beliefs of each about health care The cultural context of the encounter (e.g., hospital, clinic, home) The extent of agreement between the two persons' sets of beliefs and values

When caring for a patient from a cultural or ethnic group different from your own, it is important to perform a transcultural assessment of communication

What language does the patient speak during usual activities of daily living? How well does the patient speak and write in English? Does the patient need an interpreter? Are family members or friends available? Are there people the patient would not want to serve as an interpreter? How does the patient prefer to be addressed? What cultural values and beliefs of the patient (such as eye contact, personal space, or social taboos) may change your techniques of communication and care? How does the patient's nonverbal behavior affect the responses of members of the health care team? What are the cultural characteristics of the patient's communications with others?

linguistic competence:

ability of caregivers and organizations to understand and effectively respond to the linguistic needs of patients and their families in a health care encounter

stereotyping:

assigning characteristics to a group of people without considering specific individuality When one assumes that all members of a culture, ethnic group, or race act alike, stereotyping is at work. Stereotyping may be positive or negative. Negative stereotyping includes racism, ageism, and sexism. These are mistaken beliefs that certain races, an age group, or one biological sex is inherently superior to others, leading to discrimination against those considered inferior.

race:

division of human beings based on distinct physical characteristics Although the term ethnicity is often used interchangeably with race, these terms are not the same. Racial categories are typically based on specific physical characteristics such as skin pigmentation, body stature, facial features, and hair texture. Because of the significant blending of physical characteristics through the centuries, however, race is becoming harder to define using simple classifications, and physical characteristics are not considered a reliable way to determine a person's race. Federal standards for race classification provide five categories including American Indian or Alaska Native, Asian, Black, or African American, Native Hawaiian or Other Pacific Islander, and White, and provide the opportunity for people to identify themselves in multiple categories.

cultural respect:

enables nurses to deliver services that are respectful of and responsive to the health beliefs, practices, and cultural and linguistic needs of diverse patients; critical to reducing health disparities and improving access to high-quality health care enables nurses to deliver services that are respectful of and responsive to the health beliefs, practices, and cultural and linguistic needs of diverse patients. Moreover, cultural respect is critical to reducing health disparities and improving access to high-quality health care

You can also anticipate a patient's cultural needs by obtaining this information through research before initiating contact with the patient. Remember, however, that information about any culture is

general, and that it must be individualized for the specific patient once the actual interaction begins.

cultural imposition:

tendency of some to impose their beliefs, practices, and values on another culture because they believe that their ideas are superior to those of another person or group the belief that everyone else should conform to your own belief system

gender role behavior:

the behavior a person conveys about being male or female, which may or may not be the same as biological sex or gender identity

gender identity:

the inner sense a person has of being male or female, which may be the same as or different from biological sex; synonym for sexual identity

Religion

Dietary restrictions associated with religions might affect a patient's nutritional requirements. Many religions eschew certain types of food products. For example, Mormons do not use coffee, tea, or alcohol, and are encouraged to limit meat consumption. Hindus do not eat beef because cows are considered sacred. Many Hindus are vegetarian, adhering to the concept of nonviolence as applied to animal sources of food (Dudek, 2018; Purnell, 2013). Therefore, alternative food choices or meal patterns may be necessary. Kosher dietary laws require special food preparation techniques and prohibit intake of pork and shellfish. Thus, a patient's religious affiliation may affect that individual's nutritional regimen. Question regarding any preferences or restrictions should be included in a nutritional assessment. Vegetarian, kosher, and other special diets are available in hospitals, long-term care facilities, retirement homes, and programs, such as Meals on Wheels.

Assuring Cultural Competence in Health Care

Ensure that all patients/families receive from all staff members effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language. Implement strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area. Ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery. Offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/family with limited English proficiency at all points of contact, in a timely manner during all hours of operation. Make available easily understood patient-related materials and post signs in the language of the commonly encountered groups and/or groups represented in the service area. Ensure that data on the individual patient's/family's race, ethnicity, and spoken and written language are collected in health records, integrated into the organization's management information systems, and periodically updated. Maintain a current demographic, cultural, and epidemiologic profile of the community, as well as a needs assessment, to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area.

Meaning of Food

Food means different things to different people, with food playing multiple roles in the lives of most people. In addition to satisfying hunger and providing nutrition, food may signify a celebration, a social gathering, or a reward. Some people use various foods to indicate caring or to give comfort and reassurance during times of stress or unhappiness. Mealtime may evoke memories of family discussions, laughter, and enjoyable times. Some may remember conflicts associated with eating or avoid eating because it reminds them of their loneliness and isolation. Others, because of society's emphasis on being thin, may resort to fad or crash weight-reduction diets to resolve eating conflicts and lose weight rapidly. This initial weight reduction seldom is sustained for an extended period, and a cycle of yo-yo dieting frequently results. Drastic weight loss is followed by an eating binge that causes the dieter to regain all the lost weight and, possibly, some additional weight each time the sequence occurs. Nutritional deficiencies may occur and place the person at risk for other diseases. Losing weight and keeping it off require a change in eating habits as part of the overall commitment to health.

Food and Nutrition

Food preferences and preparation methods often are culturally influenced. Certain food groups serve as staples of the diet based on culture and remain so even when members of that culture are living in a different country. Patients in a hospital or long-term care setting often do not have much choice of foods. This means that people with cultural food preferences may not be able to select appealing foods and thus may be at risk for inadequate nutrition. When assessing the possible causes of a patient's decreased appetite, try to determine whether the problem may be related to culture. It may be possible for family or friends to bring in foods that satisfy the patient's nutritional needs while still meeting dietary restrictions. Dietary teaching must be individualized according to cultural values about the social significance and sharing of food.

Culture

Nutritional diversity is common among cultural or ethnic groups. The variety and selections are unique to each group and represent their personal beliefs and customs. Culture influences what is eaten or considered edible, how it is prepared, and what combinations of food are permitted. Herbal treatments that are popular in some cultures may interfere with or counteract the action of prescribed medication. The variations in food choices within a culture also depend on income levels and availability of foods. General and specific cultural knowledge allows the health care provider to ask the right questions when interacting with patients of varying backgrounds. The U.S. Department of Agriculture and the National Agricultural Library (2016) provide extensive resources for working with various ethnic and cultural groups at https://fnic.nal.usda.gov/professional-and-career-resources/ethnic-and-cultural-resources. Nurses who are aware of the specific needs and beliefs of culturally diverse patient populations are better able to communicate effectively and provide optimal care. Box 36-3 suggests guidelines for effective communication about nutrition with culturally diverse patients. If a patient of a different culture is to be placed on a specific diet, discussing food choice options is necessary to customize the diet to meet the person's cultural demands. Discussing ways to integrate cultural food preferences into current nutrition guidelines is an important part of nursing care.

Family, Sex, Gender, and Age Variables

Other culturally related variables are family, sex, gender, and age. A person's response to pain or symptoms may be affected or influenced by the response of family members. Spouses also may reinforce pain behavior in their partners. Children growing up in different families may learn to be brave and ignore pain or to use the pain experience to secure attention and service from family members. Family size and birth order do not appear to be significant in distinguishing chronic pain sufferers. Similarly, children may learn that there are gender differences in pain expression. It may be acceptable for a little girl to run home crying with a scraped knee, but a little boy may be told that he should be brave and not cry. Adult men and women may hold on to gender expectations regarding pain communication and incorrectly interpret the presence or absence of pain expressions in others. Women are more comfortable communicating the discomfort associated with pain, but this ability to verbalize may cause some to view the pain as emotionally or psychologically based. Data suggest that there may be a biological component to pain responses as well. The American Society of Anesthesiologists (2016) performs an annual review of the literature to describe the chronic pain experienced by women and discuss options to manage this pain. Research suggests that women are more likely to experience and suffer from pain, but more work needs to be done specific to women. In addition, different age groups have different beliefs and norms regarding pain sensation and response. At one time, the infant's inability to communicate pain led health care practitioners to the erroneous assumption that pain sensation was diminished or absent. More recently, it has been demonstrated that infants and small children are sensitive to and experience pain. Among older people, pain has often been viewed as a natural component of the aging process, being ignored or undertreated by health care providers. On the other hand, conditions normally painful in young adults (e.g., myocardial infarction) may result in minimal pain reports from older adults. An older adult not reporting pain may indicate that the person fears the treatment for the pain, the pain is dulled based on processes inherent in normal aging or chronic disease progression, or the older adult simply refuses to give in to the pain. For many older adults, pain has become accepted as a daily occurrence and is regarded as part of the normal aging process. These variables, which influence pain sensation, perception, and response, make pain assessment a complex task for the nurse.

Orientation to Space and Time

Personal space is the area around a person regarded as part of the person. This area, individualized to each person and to different cultures and ethnic groups, is the area into which others should not intrude during personal interactions. If others do not consider a person's personal space, that person may become uncomfortable or even angry. When providing nursing care that involves physical contact, you should know the patient's cultural personal space preferences. For example, people of Arabic and African origin commonly sit and stand close to one another when talking, whereas people of Asian and European descent are more comfortable with more distance between themselves and others. Many people and almost all institutions in the United States value promptness and punctuality. When arriving for an appointment, doing a job, or carrying out an activity, being on time and getting the job done promptly are viewed as important. This is not true in some other cultures. For example, in some South Asian cultures, being late is considered a sign of respect. In addition, while some cultures are future oriented (including activities that promote future good health), other cultures are more concerned with the present or the past. Understanding the patient's orientation to time is important as you communicate, for example, the need to be on time for appointments for health care procedures and when taking medications.

Religious Beliefs

Religious beliefs can be a powerful influence on the person's experience of pain. In some religions, people view pain and suffering as a lack of goodness in themselves. Thus, pain and suffering are viewed as a means of purification or of making up for individual and community sin. This meaning helps the person to cope with pain, thus becoming a source of strength. Patients with this belief may refuse analgesics and other pain relief measures, feeling that this lessens their suffering. On the other hand, illness and pain may also be viewed as punishment from a vengeful God. People may find their faith shaken and question the existence of a loving God. How can belief in a loving God be compatible with their present experience of pain? Anger, resentment, and depression may compound the pain experience. Patients may find it helpful to confer with a spiritual adviser about their pain experience.

Cultural Assessment

The National Center for Cultural Competence urges health care professionals who value cultural competence to enhance their understanding of the following: Beliefs, values, traditions, and practices of a culture Culturally defined, health-related needs of individuals, families, and communities Culturally based belief systems of the etiology of illness and disease and those related to health and healing Attitudes toward seeking help from health care providers When caring for patients from a different culture, it is important to first ask how they want to be treated based on their values and beliefs. An effective way to identify specific factors that influence a patient's behavior is to perform a cultural assessment. The primary informant should be the patient, if possible. If the patient is not able to respond to the questions, a family member or a friend can be consulted. A useful tool for this is the Andrews and Boyle Transcultural Nursing Assessment Guide (2016). The Giger and Davidhizar model takes into account six cultural phenomena: communication, space, social orientation, time, environmental control, and biologic variations. The Campinha-Bacote Model of Cultural Competence (2011) emphasizes becoming culturally competent and integrating cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire.

Transcultural Assessment: Health-Related Beliefs and Practices

To what cause(s) does the patient attribute illness and disease (e.g., divine wrath, imbalance in hot/cold or yin/yang, punishment for moral transgressions, hex, soul loss, pathogenic organism)? What are the patient's cultural beliefs about the ideal body size and shape? What is the patient's self-image compared to the ideal? What name does the patient give to his or her health-related condition? What does the patient believe promotes health (e.g., eating certain foods; wearing amulets to bring good luck; sleep; rest; good nutrition; reducing stress; exercise; prayer; rituals to ancestors, saints, or intermediate deities)? What is the patient's religious affiliation (e.g., Judaism, Islam, Pentecostalism, West African voodooism, Seventh-Day Adventism, Catholicism, Mormonism)? How actively involved in the practice of this religion is the patient? Does the patient rely on cultural healers (e.g., curandero, shaman, spiritualist, priest, minister, monk)? Who determines when the patient is sick and when the patient is healthy? Who influences the choice/type of healer and treatment that should be sought? In what types of cultural healing practices does the patient engage (e.g., use of herbal remedies, potions, massage; wearing of talismans, copper bracelets, or charms to discourage evil spirits; healing rituals, incantations, prayers)? How are biomedical/scientific health care providers perceived? How do the patient and the patient's family perceive nurses? What are the expectations of nurses and nursing care? What comprises appropriate "sick role" behavior? Who determines what symptoms constitute disease/illness? Who decides when the patient is no longer sick? Who cares for the patient at home? How does the patient's cultural group view mental disorders? Are there differences in acceptable behaviors for physical versus psychological illnesses?

Ageism

a form of prejudice, like racism, in which older adults are stereotyped by characteristics found in only a few members of their group. Fundamental to ageism is the view that older people are different and will remain different; therefore, they do not experience the same desires, needs, and concerns as other adults. Our industrial technologic world places a high priority on productivity, and some may think that older employees or retired people have outlived their usefulness. Older people may be incorrectly viewed as being rigid or narrow-minded, unable to learn, unreliable because of memory loss, too old to enjoy sexual pleasure, or childlike and dependent. Many people fear advancing age because of pervasive views that older people are poor, lonely, in frail health, and headed for institutionalization in a long-term care facility. These descriptors are not true for most older adults Most older adults are satisfied with their lives, finding retirement and old age more enjoyable than they had anticipated. Most older adults live in homes or apartments (96%), with the likelihood of living in a long-term care facility increasing as the person ages. Older women are less likely to be married and more likely to live alone. In fact, 27% of women aged 65 to 74, 42% of women aged 75 to 84, and 56% of women aged 85 and older live alone. Most older adults maintain close ties with their families, and 90% of older adults have incomes above the poverty level

A person's culture may determine how much sensory stimulation is considered

normal. For example, the amount of touching a child experiences in a family that is physically demonstrative may be different from that experienced by a child in a family that is less so. Ethnic norms, religious norms, income group norms, and the norms of subgroups within a culture all influence the amount of sensory stimulation a person seeks and perceives as meaningful. Moreover, sensory deprivation, sensory overload, and sleep deprivation are all related to or affected by a person's cultural practices, values, and beliefs. The nurse who is sensitive to the patient's culture attempts to determine what constitutes acceptable levels of stimuli from the patient's viewpoint. For example, certain cultures view touching as a natural and welcome custom, whereas other cultures may view it as insulting or offensive. Similarly, patients may find comfort in cultural and religious symbols of care and healing that are absent in a hospital environment. Thus, nurses must be aware of the aspects of the patient's culture to deliver culturally competent care.

cultural assimilation:

process that occurs when a minority group, living as part of a dominant group within a culture, loses the cultural characteristics that made it different When a minority group lives within a dominant group, many members may lose the cultural characteristics that once made them different, and they may take on the values of the dominant culture. This process is called cultural assimilation or acculturation. For example, when people immigrate and encounter a new dominant culture as they work, go to school, and learn the dominant language, they often move closer to the dominant culture. The process and the rate of assimilation are individualized. Mutual cultural assimilation also occurs, with both groups taking on some characteristics of the other. For example, many Hispanic immigrants to the United States learn to speak English, and many Americans learn to cook and enjoy traditional Hispanic foods. We all gain from the many cultures with which we live. Although we seldom think about it, the clothes we wear, the foods we eat, the music we enjoy, many of the words we use, and the leisure activities we practice are all influenced by acculturation.

culture:

sum total of human behavior or social characteristics particular to a specific group and passed from generation to generation or from one to another within the group shared system of beliefs, values, and behavioral expectations that provides social structure for daily living. The NIH defines culture as the combination of a body of knowledge, a body of belief, and a body of behavior. Elements include personal identification, language, thoughts, communications, actions, customs, beliefs, values, and institutions that are specific to ethnic, racial, religious, geographic, or social groups. For nurses who practice person-centered care, these elements influence beliefs and belief systems surrounding health, healing, wellness, illness, disease, and delivery of health services. Culture influences roles and interactions with others as well as within families and communities, and is apparent in the attitudes and institutions unique to particular groups

cultural blindness:

the process of ignoring differences in people and proceeding as though the differences do not exist occurs when one ignores differences and proceeds as though they do not exist. Cultural imposition and cultural blindness can be observed within the health care system, especially in regard to nontraditional methods of care.