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Self-Health Assessment With Reference to Family Genogram Report (Assessment)

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Learning more about wellness, making useful decisions, and planning for a healthy future has become important. The wellness revolution has come to stay: it spreads the message of wellness and health awareness on a global proportion. Remaining active through physical exercise is the first step. Recognizing shortfalls and developing strategies to cope with them is the next. Setting personal goals is important for achievement.

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Measures to defeat problems of environmental and unhealthy practices, seeking social acceptance and financial stability are the recommendations to open up the pathway to wellness. Wilma, a student nurse has analyzed the features of her health assessment and family health assessment and concerning the family genogram. She has made a wellness plan for herself which would create changes in her physical and mental make-up enabling her to accomplish a healthy life for a long period.

Analysis of Self Health Assessment
Health perception-health management

Being alert and oriented with no learning disabilities or deafness and generally well-nourished has helped the client’s status to be good. The sensations of light touch and coarse touch, heat and cold are all intact. Smelling odors are no problem. Having had no reason for taking to substance abuse things were fine till hypothyroidism affected her. The only medicine consumed was the levothyroxine for the hypothyroidism (Refer to Appendix A) Immunization status was near perfect, having had all the immunizations prescribed by the health recommendations but not having been immunized for human papillomavirus and meningococcal meningitis prevented her from reaching the perfect immunity status. (Refer Appendix A).

The last annual physical checkup was in the previous March and this annual checkup kept updating her on their health status. The workplace was excellent for work with good ventilation, lighting, heating, cooling, and water. The home was also excellent but the problem of space was there along with the lack of facilities like the telephone for public use, pharmacy, health care facility, and transportation. There was no history of accidents or falls with her extra care in driving with the seatbelt and not succumbing to distractions while driving (Refer Appendix A) Definitions of health and illness differed greatly from modern views in their culture (Bellack and Edland, 1992).

Nutritional-metabolic pattern

Being well-nourished and managing the weight steadily in the last six months had been an achievement. The voracity of appetite is not her habit and food intolerance had never occurred to her yet. (Refer Appendix A) Eating whatever was offered if she so required something, had been her forte. Keeping a regular 3 meals daily and some snacks, her consumption of water was 4 bottles and adequate. The pasta was something she liked but sweets were not. Putting on a little weight may have been alright by her but her active lifestyle was not to be disturbed. Overweight and obesity were defined as abnormal or excessive fat accumulation that presented a risk to health (Global strategy, WHO).

By these standards, obesity was not her problem. Judi Daniels, a practicing family nurse practitioner and a professor at the University of Kentucky’s College of Nursing, has highlighted the consequences of obesity (2006). The risks of “diabetes, heart disease, dyslipidemia, arthritis, sleep apnoea, cancer of the breast” among many other cancers have been reported as being the consequences. (Daniels, 2006). Daniels also noted that the average American diet usually exceeded the recommended amounts of fats, carbohydrates, and proteins. This is a warning to the client who was prone to obesity considering the family history. Experience had taught her to have a yearly check-up which keeps her informed about unsuspected ill-health. The last had been in March 2009. (Refer Appendix A)

Elimination pattern

Elimination patterns were normal. (Refer Appendix A) Regular bowel habits and absence of constipation had been the habit. When diagnosed with hypothyroidism, one of her main complaints was constipation. After starting on levothyroxine, this complaint had left her. (Refer Appendix A) Micturition had never given her any problem: The urine output was around 1500ml.-2000 ml. No definite figure has been put as normal as output would depend on many factors like intake (Wallach, The Milwaukee Journal) Considering her intake of water, her urine output appeared to be normal.

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Activity-exercise pattern

The level of activity was good. Doing chores like vacuum cleaning, car wash, cleaning had become a habit (Refer Appendix A). Not having the time, indulging in any formal exercise programs had been out of the question. It is said that 40% of women and 35% of men do not exercise by the assessment made for Healthy People 2010. (Daniels, 2006). Those who did not exercise were found to have a 2.5 times higher risk for gaining weight when compared to those who exercised. The reasons given for the lack of exercise in many people were the modernization of houses and appliances, sedentary occupations, low socioeconomic status, and communities not planned for outdoor activities (Daniels’, 2006)

It is worthwhile remembering Daniels’ advice for exercise. The client’s BMI was 19, within normal limits. Normal Body Mass Index is 18.5 t0 24.9. “BMI is the measure of body fat based on height and weight applicable to men and women”. (BMI, NHLB Institute).

Sleep rest pattern

Sleep lasted about 6-8 hours but was disturbed and the feeling of having rested was lost. Taking naps may have helped but this was not possible due to lack of time. Getting up early at 5.30 a.m. appeared to be a problem but medication had not been tried for it. This sleep disturbance remained an area of concern. Knowing that more and higher quality of sleep improves health, well-being, and performance, the worry remained as to how to solve this problem. (Characteristics of sleep, Harvard Medical School)

Cognitive perceptual pattern

Cognitive self-being seemingly perfect, it was easy to make decisions rapidly and gauge current problems. Their calm composure and positive attitude helped her in her endeavors. The feeling of gratitude to her parents for providing the strict and orthodox background that had held her steady till now made her happy.

Self-perception and self-concept patterns

The excellent workplace, where she was a lab technician assistant, was another source of delight and satisfaction; stressful noises, deficiency of space, too much heat or too much cooling, scarcity of water, or lack of ventilation did not trouble her. However, the living area was small and made her stuffy at times. Moreover, there was no grocery store or pharmacy or health care facility or nearby transportation or even a telephone to call the police or fire brigade or ambulance. Being careful when driving and using her seat belt, an accident had never occurred in her life. Despite her fairly good health, fatigue overcame her at times.

Role-relationship pattern

This was well established in her home. The relationship that she had with the members of her family was warm and sincere. So was her commitment to nursing. Knowing her place in both situations, efforts were helping her to be committed to both. Culture had allowed her to learn values, beliefs, and customs which her close family members shared. Staying in Columbus for the past five years, keeping regular contact with her parents’ siblings and their children had been pleasurable. Meeting the family had become difficult now with them living elsewhere.

Sexuality-reproductive pattern

Not having married, this subject was irrelevant. However, menstrual cycles were normal and sexual life was problem-free for her. Pap smears were taken yearly as a precaution against cancers. They were cervical smears taken to rule out cervical cancers. Researchers think that the Pap smears need be done only every 3 years if the client had three clean smears previously as the cervical cancers are slow-growing. (Sinnema, 2009)

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Coping-stress tolerance pattern

Handling of stress was good. No traumatic or stressful events had taken place in school. When any stressful event occurred, talking to a friend had eased matters. Never having had an occasion to undergo support or group counseling, the family had always managed to make solutions for problems.

Value-belief pattern

Happiness and experiencing normal changes in life had kept her satisfied with the life pattern. Nursing would not interfere with religious and spiritual practices. Religious practices had not interfered with being involved with blood transfusion or diet or surgery. On the contrary, it had helped solve problems. Feeling calm and composed after prayer, absolute satisfaction was the result.

Analysis of family cultural assessment

Being born in Somalia, the client’s grandparents and parents found it difficult when they migrated to America; the parents were 50 and 40 years of age and the grandfather was 71. They consider themselves African Americans. (Refer Appendix B) Having been raised in suburban surroundings, the transition to the US was difficult for the client as an 18-year-old. Having had a good family life all through and indulging in their traditional food of rice and lamb meat and trying various foods were pleasures. Greater morbidity has been found among migrants (Kristiansen, 2007). However, it is usually the healthy people who migrate.

Mental health problems and risk behaviors are possible. Health behavior is affected by the minority status, minimal socialization, and identity processes (Kristiansen, 2007). The psychosocial strains could have hurt mental health and caused stress. These were not experienced by the client’s family as the structural and cultural barriers would have been reduced and disease prevention interventions taken by the immigration authorities (Kristiansen, 2007).

The client and family did not have any problems following the migration except for an adjustment problem which they managed to overcome with time. Resorting to home remedies, washing hands often and frequent prayer were their traditional techniques of overcoming illnesses. The gender or ethnicity. of the healthcare provider did not matter as it was their health that mattered more. Restrictions did not count and they reacted according to the situation in case of blood transfusions or surgery. Burial was the form of death rites followed. As far as possible, a comatose patient was not allowed to remain indefinitely on the ventilator.

Mothers had their babies spaced out by at least two years and they needed to stay at home with them for a year at least. Reading the Quran in illness was their belief in getting relieved and the health care provider was expected to understand their belief. Barriers did not play any role as all their friends were of the same faith. These practices had been very much a part of their lifestyle. However, the health recommendations did not see things in the light of their traditional culture. Home remedies did not always work.

Strengths and areas of concern

Washing hands may have been a strength as it helped in preventing the onset of many illnesses but this traditional practice was not foolproof. Stopping the transmission of bacteria or viruses through the aerial route or even by contact or through food and water was not possible and this was an area of concern. Health recommendations included the use of specific medication for illnesses and everything had a scientific reason.

Cultural traditions lacked this and this was a drawback. Surgical or other interventions like blood transfusions were necessary for many illnesses in the health recommendations and they were justified with reason; their strength was that the sex or ethnicity of a health care provider or the acceptability of the intervention hardly mattered when health was at stake. Prayer was a strength for providing relief of mental tension and stress but it was insufficient for healing where medicines and appropriate interventions were necessary. A good family environment with sufficient support from all was another strength. Spacing babies was a strength that was similarly said in the Health recommendations. Reading the Quran was good for holistic relief but it was not an absolute method for relief of illness.

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Analysis of family history genogram

A history of heart attack and diabetes existed in her paternal grandparents. Being overweight, one of her aunts on the father’s side had diabetes (Refer Appendix C). Infertility was a problem for one uncle. Only back pain affected her father. Of the maternal grandparents, the grandfather was affected by lymphoma and the grandmother by a stroke. Hypertension was found in a maternal uncle. A high cholesterol level and Vitamin D deficiency were the “illnesses” her mother had (Refer Appendix C) The risks of hypertension, hypercholesterolemia, stroke, diabetes, and obesity were greater for her and these were areas of concern as they were the leading cause of mortality on a global proportion (Global strategy, WHO).

Obesity with its complications accounts for 1.6 billion adults. This area of concern, obesity, must have been the beginning of the various illnesses of her family. Longevity was seen in both the parents’ families and this was a strength. (Refer Appendix C) Most of the members were educated and working giving the impression that they were intelligent people. The ability had probably carried onto her. They were not people who needed to live on welfare and outside help. The likelihood that the siblings and the client would do well in their lives was a strength.


Alertness, intelligence, good physical health, and the intact senses began her strengths. Possessing no habituation, having been brought up on a healthy home diet, happiness in a close-knit family, and having been able to avoid accidents through careful driving were her other added strengths (Refer Appendix A). Not being obese was a strength. Being able to maintain a calm composure and a positive attitude had helped her maintain her sociability and for making rapid decisions. Her standard of the English Language had helped her progress in life in America though her native language was Somali. The excellent workplace and home had been instrumental in building her positive attitude. Strong religious backing, cultural traditions, and the family atmosphere had also enhanced her strengths. The chance of having a long life was another strength awarded by way of the family heredity. (Refer Appendix C).

Areas of concern

Where health was considered, hypothyroidism and visual defect may be areas of concern. However, consuming appropriate treatment for hypothyroidism had eliminated problems associated with it. Glasses had compensated for the visual defect, so this also could not be thought of as an area of concern. Having been advised to keep her weight regular, it was being maintained by consuming less fat and more vegetables and fruits.

Not being overweight and the BMI being just 19, obesity problems were out of the focus for the present. However with great risk factors in the family, and knowing that overweight and obesity could give rise to diabetes, cardiovascular diseases, and cancers, keeping weight down was necessary (Global strategy, WHO). Living quarters were an area of concern. Having superstitious beliefs which may have harmed some of her thoughts, the decision to change her ways had taken hold of her. Religious and ethnic beliefs had helped her but she knew that they may not answer many of her health’s riddles. Keeping only friends of her faith had not helped socially.

The sleep pattern was disturbing: she felt tired the next day. To date, she had not been able to make up for her lack of proper sleep which was an area of concern.

Personal Wellness Plan

The Penders’ Health Promotion model allows a behavior change if a positive personal value is strongly believed in (Larsen and Lubkin, 2008). Understanding that religious and ethnic beliefs could not answer for many of the health problems in this world, a change was necessary. With her having chosen nursing as a profession, it was time, that tried and tested medical reasons for illness and health were understood. Superstitions had to give way to progressive ideas.

Greater self-efficacy and a positive outcome had helped her seek more committed roles. Barriers were not to be allowed to stop her. Remembering the cultural diversity of this world, making more friends, and interacting with more patients of multicultural origin were to be her preoccupations. Now that she had joined nursing, she plans to have friends without knowing which religion they follow had to be executed. The diversity of religion and ethnicity was to be enjoyed. All religions were good and needed to be understood. Her social and interpersonal wellness was to be asserted by her making friends freely.

To increase physical wellness, sleep deprivation and sleep debt must be reduced (Jha, 2001). The sleep problem affected her cognitive level the next day and the following days. Sleep deprivation in one night becomes worse the next day and causes a reduction in the cognitive level by 25 % and if this goes on, by 40% the following day (Cox, 1989). Sleep debt occurs when a person has sleep deprivation for many days. If she was to be at her peak level of action and alertness, ways to reduce or remove her sleep disturbances were to be found. She planned to have a small meal in the late evening, some exercise before that, and a peaceful reading of a romantic novel just before sleep.

The causes of obesity are “excessive energy intake from high-fat foods, refined sugars, alcohol, and limited consumption of fruits, vegetables, and high fiber foods” and a decrease in physical activity mainly by taking up occupations that restrict activity (Schmidl, 2007). Physical exercise, which was one way to control obesity, had to be done enjoyably. The fat intake had to be reduced and the intake of vegetables and fruits increased so that it placed her in a safer position especially as the family members had illnesses like diabetes, hypertension, cardiac disease, and hypercholesterolemia putting her at risk. A short period of daily exercise was good for keeping the weight steady. The gymnasium attached to the nursing school where she was studying was a good place to work out.


This goal of highlighting and analyzing the related health aspects has been achieved. This client has achieved the goal of completely analyzing the assessments of her health and family health and planning for interventions that would help change her behaviors to suit the multiculturally diverse world and improve her health along with by reducing the risks that she has become prone to buy her family genogram. Her areas of concern have been tackled with positive interventions which would change her weaknesses into future strengths. As the WHO definition of health states, the state of complete physical, mental and social well-being describes her well.

It can be said that attaining physical wellness, emotional wellness, intellectual wellness, spiritual wellness, social wellness, and environmental wellness has been a success. Speaking of problems, the only illnesses that can be spoken of are hypothyroidism for which treatment is being taken, and a visual defect for which spectacles are being worn. This completes physical wellness. The strong chance of progressing into obesity and becoming exposed to the risks of illnesses that persist in the family is a weakness. The family genogram tells about proneness to obesity and its associated illnesses.

Keeping all these in mind, a wellness plan has been chalked out to be implemented so that a healthy life can be led all through. Physical wellness is once again reassuring. Joining nursing has ensured emotional and social wellness as this is the job that will give maximum satisfaction and dreams of selfless service will be fulfilled. Staying in the nursing residential quarters, the atmosphere change may be good for environmental wellness.

Spiritual wellness is what has been had already through religion. Using the Health promotion model, the narrow thoughts about the disease and ill health are already undergoing a transition for making a better-oriented person soon through nursing education strengthening the social wellness. The small problem of sleep will be corrected as early as possible and boosting physical wellness will make Wilma a person with all-around wellness.


Bellack, J.P. & Edland, B. (1992). Nursing Assessment and diagnosis. Jones and Bartlett Publishers BMI. Web.

Cox, T.K. GP Ed. Stress and Sustained performance, 1 Ed, 1989, Work and Stress, No. 3 Global strategy, World Health Organization. Web.

Daniels, J. (2006). Obesity: America’s Epidemic. AJN, Vol. 106, No.1, Lippincott, Williams and Wilkins.

Jha, A.K., Duncan, B.W. &Bates, D.W. (2001). Fatigue, sleepiness and medical errors in Making health safer: A critical analysis of patient safety practices. (Ed. ) Markowits, A.J., University of California, San Francisco, Prepared for the Agency for Healthcare Research And Quality.

Kristiansen, M. (2007). Health effects of migration. Danish Medical Bulletin, Vol. 54, p.47-47.

Larsen, P.D. and Lubkin, I.M. (2008). Chronic illness: Impact and interventions, Jones and Bartlett Publishers.

Sinnema, J. (2009). Pap smear guidelines may bring relief. The Edmonton Journal. Web.

Schmidl, M. (2007). Obesity, International Union of food science and technology (IUFoST). IUFoST Bulletin.

Wallach, J. (1995). Person’s urine output should equal fluid intake. Web.

The Milwaukee Journal

WHO definition of Health, Preamble to the Constitution of the World Health Organisation as adopted by the International Health Conference, New York, 19-22 June, 1946by the representatives of 61 States (Official Records of the WHO, No. 2, p. 100) and entered into force on 7 April, 1948.

Appendix A
Self Health Assessment

Complete the 212 F09 Gordon’s Health Patterns Self Health Assessment instrument provided. Submit your raw data (the completed form) as an Appendix with your paper. To assist in your analysis, also visit MyPyramid at http://mypyramid.gov. Input your height, weight, and activity level. Consider the site’s feedback and suggestions for healthy living. The feedback I got was; exceed the limit of fat intake and less fruit and vege. The activity was very good even though I didn’t exercise. (I did house choirs) ex; vacuum, car wash, cleaning, etc. Also, my BMI is 19 (normal).

212 F 09 Gordon’s Health Patterns SELF HEALTH ASSESSMENT


Date: 09/27/09 Time: 5:00pm

Name: xxxx, xxxxx

Date of Birth: Age: Sex: f

Primary significant other:

Developmental Stage Young Adult 18-25 yrs __Young Adult 25-35 yrs _√ __

Do you have any allergies? No__ Yes √ _ What? Hay fever seasonal allergy

(Check reactions to medications, foods, cosmetics, insect bites, etc.)

Health Perception-Health Management Pattern

Mental Status Alert & Oriented? Yes_√ No__

Learning disabilities or special needs:

Visual acuity: need glasses

Vision aids: glasses

Last eye doctor visit: May 2008

Able to hear? Yes_√ _ No__

Hearing aids: N/A

Able to taste? Yes_√ _ No__

Able to sense blunt, sharp, light touch, heat, cold? Yes √ __ No__

Any numbness or tingling? N/A

Able to sense odors? Yes_√ _ No__


Describe your usual health status? Good_√_ Fair__ Poor__

Are you satisfied with your usual health status?

Yes, _√__ No__ Source of dissatisfaction:

Nicotine use? No_√__ Yes__ Amount per day:

Caffeine use? No_√__ Yes__ Amount per day:

Alcohol use? No_√__ Yes__ How much and what kind?

Street drug use? No_√__ Yes__ What and how much?

Any history of chronic disease? No__ Yes_√__ Describe: Hypothyroidism

Immunization history: Tetanus_√__ Pneumonia__ Influenza_√__ MMR_√___ Polio √___ Hepatitis B_√__ Human Papilloma Virus ___ Meningococcal meningitis ___

Have you sought any health care assistance in the past year? No__ Yes_√___ If yes, why?

Last physical examination: March 2009

Are you currently working? No__ Yes_√__ How would you rate your working conditions? (e.g. safety, noise, space, heating, cooling, water, ventilation)? Excellent_√___ Good__ Fair__ Poor__ Describe any problem areas:

How would you rate living conditions at home? Excellent_√__ Good__ Fair__ Poor__ Describe any problem areas: I live in an apartment and sometimes there is not enough space

Do you have any difficulty securing any of the following services?

Grocery store: Yes:__ No:_ √_; Pharmacy: Yes__ No √___; Health Care Facility: Yes:__ No:_ √___; Transportation: Yes:__ No:_ √__; Telephone (for police, fire, ambulance): Yes:__ No:_ √__

Medications (over-the-counter and prescription)

Drug Dose Times per Day Reason Taking as Ordered
levothyroxine 50MCG One tablet QD Hypothyroidism Yes_√_ No__

Have you had any accidents/injuries/falls/surgeries in the past year?

No: √ Yes__ Describe:

Do you exercise regularly?

No_√ _ Yes__ Type & Frequency:

Do you use seat belts? Yes__√ __ No__

Use a cell phone, eat, or apply makeup while driving? Yes _ No_√ _

Nutritional-Metabolic Pattern

Skin examination Warm__ Cool__ Moist_√ _ Dry__ Intact?

Teeth: Normal_√ _ Abnormal__ Describe:

Able to chew & swallow food without pain? Yes_√ _ No__

Last dentist visit:


Any weight gain in the last 6 months? No__√ __ Yes__ Amount:

Any weight loss in the last 6 months? No___√ __ Yes__ Amount:

How would you describe your appetite? Good__ Fair_√ _Poor__

Do you have any food intolerance? No_√ _ Yes__ Describe:

Do you have any dietary restrictions? (Check for those that are a part of a prescribed regimen as well as those that patient restricts voluntarily, for example, to prevent flatus) No_√ _ Yes__ Describe:

Describe an average day’s food intake for you (meals and snacks): 2-3 meals and snacks

Describe an average day’s fluid intake for you. About4 bottles of fluid

Describe food likes and dislikes. I like pasta, I don’t like too many sweets.

Would you like to: Gain weight?_√ Lose weight?__ Neither__

Any problems with Nausea, Vomiting, Swallowing, Chewing, Indigestion? No_√ _ Yes__ Describe:

Would you describe your usual lifestyle as Active_√ _ Sedate__

Elimination Pattern

What is your usual frequency of bowel movements?

Have to strain to have a bowel movement? No_√ _ Yes__

Character of stool

Consistency: Hard__ Soft_√ _ Liquid__

Color: Brown___√ _ Black__ Yellow__ Clay-colored__

Bleeding with bowel movements: No_√ _ Yes__

History of constipation: No_√_ Yes__ How often?

Do you use bowel movement aids (laxatives, suppositories, diet)?

No_√__ Yes__ Describe:

Usual voiding/urination frequency (times per day) 4-5 times

Color: Yellow_√__ Smokey__ Dark__

Incontinence: No_√_ Yes__ When?

Pain/burning: No_√__ Yes__ Describe:

Activity-Exercise Pattern


Extremities: Temperature Cold__ Cool_√__ Warm__ Hot__

history of heart problems? No_√_ Yes__ Describe:

Respiratory rate ( # breaths in 60 seconds) 20/min

Walk in place for 3 minutes:

Any shortness of breath after activity? No_√__ Yes__


Any pain on moving? No_√_ Yes__

Any difficulty moving? No_√_ Yes__

Posture: Upright Normal_√__ other ___


Rate each self-case area below on a scale of 0 to 4. (Scale has been adapted by NANDA from E. Jones, et. Al., Patient Classification for Long Term Care; User’s Manual. HEW Publication No. HRA-74-3107, November 1974.)

0 – Completely independent

1 – Use of equipment or device

2 – Need help from another person for assistance, supervision, or teaching

3 – Need help from another person and equipment device

4 – Dependent; does not participate in an activity

Feeding_0_; Bathing/hygiene_0_; Dressing/grooming_0_; Toileting_0_; Ambulation_0_; Care of home_0_; Shopping_0_; Meal preparation_0; Laundry_0_; Transportation_0_

How many pillows do you use to sleep on? one

Do you frequently experience fatigue? No__ Yes_√__ Describe: I feel tired all the time

Occupation (if retired, former occupation): Lab tech assistant

Describe your usual leisure time activities/hobbies: Watch TV, walking

Any problems with concentration? No_√__ Yes__ Describe:

Sleep Rest Pattern

Usual sleep habits: Hours per night 6-8 hours; Naps: No_√_ Yes__ a.m.__ p.m.__ Feel rested? Yes,__ No_√_ Describe: I wake up early so most of the time I get tired quickly, I need naps but don’t get a chance to do that.

Any problems Difficulty going to sleep, Awakening during the night, Early awakening, Insomnia? No__ Yes√___ Describe: my usual wake up time is 530am

Methods used to promote sleep, e.g., Medication, Relaxation techniques: No_√__ Yes__ Describe:

Cognitive Perceptual Pattern

Pain No_√__ Yes__ If yes

If yes:


Intensity (rank on a scale of 0 to 10):

Radiation: No_√__ Yes__ To where?

Timing (how often: related to any specific events):


What done relieve at home?

When did the pain begin?

Decision-making is Easy_√_ Moderately easy__ Moderately difficult__ Difficult__

Inclined to make decisions: Rapidly_√__ Slowly__ Delay__

Knowledge level

Can define what current problems is: Yes_√__ No__

Self-Perception and Self-Concept Pattern

Currently feeling: Calm√___ Anxious__ Irritable__ Withdrawn__ Restless_


What is your major concern at the current time?

Do you think the nursing student role will cause any lifestyle changes for you? No_√__ Yes__ What?

My usual view of myself is: Positive_√__ Neutral__ Somewhat negative__

What problems do you think you’ll experience with being a nursing student? Describe: No

On a scale of 0 to 5 rank your perception of your level of control in this situation: 4

On a scale of 0 to 5 rank your usual assertiveness level: 3

Role-Relationship Pattern

Speech Pattern

Is English your native language? Yes__ No_√_

If not, the native language is: Somali

If no, on a scale of 0 to 5 rate your comfort reading, speaking & understanding English: 5


Do you live alone? Yes,__ No_√_ With whom? I live with my family

Are you married/in a relationship? Yes,___ No_√__ Children? No_√__ Yes___ Ages of Children:

How would you rate your parenting skills? Not applicable_√__ No difficulty__ Average__ Some difficulty__ Describe:

Any losses (physical, psychological, social) in the past year? No_√__ Yes__ Describe:

If yes, how are you handling this loss at this time?

Will the nursing student role result in any type of loss? No_√__ Yes__ Describe:

Will the nursing student role cause any significant changes in your usual family role? No_√__ Yes__ Describe:

How would you rate your usual social activities? Very active__ Active√___ Limited__ None__

How would you rate your comfort in social situations? Comfortable_√__ Uncomfortable__

What activities or jobs do you like to do? Describe: I like to help people who need help

What activities or jobs do you dislike doing? Describe: none

Sexuality-Reproductive Pattern

Date of LMP: 09/24/09 Any pregnancies? No_√__ Yes__

If yes, # times pregnant: # live births:

Use of birth control measures? No_√__ N/A__ Yes__ Type:

Pap smear annually: Yes √___ No__ Date of last pap smear: 04/01/09

Date of the last mammogram: N/A

History of sexually transmitted disease: No_√__ Yes__ Describe:


History of prostate problems? No__ Yes__ Describe:

Date of last prostate exam:

History of sexually transmitted diseases: No__ Yes__ Describe:


Experiencing any problems in sexual functioning? No_√_ Yes__ Describe:

Satisfied with your sexual relationship? Yes,_√_ No__ Describe:

Do you believe being a nursing student will have any impact on sexual functioning? No_√__ Yes__ Describe:

Coping-Stress Tolerance Pattern

Overt signs of stress (crying, wringing of hands, clenched fists, etc)? Describe:


Have you experienced any stressful or traumatic events in the past year in addition to admission to nursing school? No_√__ Yes__ Describe:

How would you rate your usual handling of stress? Good_√_ Average__ Poor__

What are your primary ways of dealing with stress or problems? Calm myself talk with close family or friends.

Have you or your family used any support or counseling groups in the past year? No_√_ Yes__ Group name:

Was the support group helpful? Yes,__ No__ Additional comments:

Are you currently using a nursing student support group? No_√__ Yes__


Are you satisfied with the care you have been giving yourself at home? No__ Yes _√_ Comments:

Value-Belief Pattern
Alterations in mood (anger, crying, withdrawal, etc.)? Describe: I feel normal (happy)
Satisfied with the way your life has been developing? Yes_√__ No__ Comments: I’m very happy with my life.
Religion: Protestant__ Catholic__ Jewish__ Muslim_√_ Buddhist__ None__ Other:
Will your nursing student role interfere with your spiritual or religious practices? No √_Yes__ How?
Any religious restrictions to care (diet, blood transfusions)? No √ Yes__ Describe:
Have your religious beliefs helped you to deal with problems in the past? No__ Yes_√_ How? When I pray I feel calm, relieved, heal better and quick.
Appendix B
Family Cultural Assessment

Answer these questions to augment your Self Health Assessment. These questions can help you further investigate your own ethnic, cultural, and spiritual heritage and help you determine how deeply you identify with particular cultural traditions. Understanding your cultural traditions can be most useful in setting the stage for understanding your future clients’ health traditions. Each question may be answered with a simple statement or short answer. For this part of the assessment do not worry about using APA writing style or references.

Your Parents and Grandparents

In what geographic area of the United States or elsewhere were your grandparents and parents born and raised? If your grandparents and/or parents were born and raised outside of the United States, how old were they when they came to the United States?

My Grandparents and my parents were born in Somalia, my grandfather was 71 years old and my mother was 40 years old and my father was 50 years old.

What ethnic group(s) do you identify for your grandparents and parents?



Growing Up

In what country and setting did you grow up (e.g. urban, suburban, rural)? If you were not born and raised in the United States, how old were you when you came to the U.S.?

I grew up in a suburban area. And I was 18 years of age.

With whom did you live while growing up (grandparents, parents, siblings, and extended family members, etc…..)?

When I was growing up I was living with my parents and siblings

When you were a child what types of food did you eat?

As a child, I used to eat a lot of different food but my favorite was pasta.

What foods are family favorites or are considered traditional?

Rice and lamb meat


Describe in detail the geographic and physical situation in which you currently live. How long have you lived there? Who lives there with you?

I live in northeast Columbus, I lived there for about 5 years and I with my family

With whom in your family do you currently have regular contact, e.g., aunts, uncles, cousins, brothers, sisters, parents, your children?

I have contact with my aunts, brothers, uncles, parents, and cousins

How often do you currently visit your family members who live/lived outside your home e.g., visit grandparents daily, weekly, monthly?

My family don’t live in the same city so I don’t get to see them often

Recalling your answer to the Self Health Assessment question on your religious faith, do you currently belong to a religious faith organization? If so, how often do you attend your faith organization e.g. never, daily, weekly, monthly, holidays?

I usually attend monthly and holidays.

Do you practice your faith in your home? If yes, please specify how e.g., prayer, holy book reading, diet observations, fasting, specific holiday celebrations, etc.

I practice my faith in my home by praying five times a day, we do fasting one

Month in the year and we celebrate twice a year.

What do you believe are the causes of illness and disease? What is the role of your religious beliefs and practices regarding health and illness?

Illnesses and diseases are part of the test from god to check our tolerant

My religious beliefs are that a person should believe that it’s from God and pray that God gives you health.

With what ethnic group(s) do you personally identify?


Do you participate in ethnic activities? If yes, please specify e.g., singing, holiday celebrations, dancing, festivals, costumes, etc.


What are the gender-specific roles and responsibilities of men and women within your cultural/ethnic/faith group?

In my culture, the man is the breadwinner of the house and the woman takes care of the children.

What are the roles and/or importance of children in your cultural/ethnic/faith group?

The importance of the children is to be obedient to their parents, and have a good attitude in society.

Your Healthcare Restrictions, Preferences, Beliefs, and Practices

How have your beliefs about the cause of illness and disease changed from what they were as a child or from what you might have been told by your parents/family?

Nothing has been changed.

What is the first thing you usually do when you think you are “sick”?

Clean my hands more often, pray that God gives you relief.

What home remedies or “cures” do you try or use before you seek professional healthcare? For what illnesses would you refuse to seek professional healthcare?

I message my body with black seed oil; eat soup with black paper, garlic, and meat. I refuse to seek health care professionals if I have the flu and virus.

What special health or healing practices do you practice not related to your religious faith?

Rest a lot and eat healthily

What restrictions, preferences, beliefs or practices do you have regarding the gender of your healthcare provider?

I believe when it comes to your health it does not matter the gender of the healthcare provider.

What restrictions, preferences, beliefs or practices do you have about medical procedures care e.g., blood transfusions or surgery, and why?

I believe if I need a procedure done or blood transfusion or surgery for my health it shouldn’t be any restrictions.

What restrictions, preferences, beliefs or practices do you have related to death, dying, or concerning those who have died?

In my culture, we believe that everybody is going to die when their time is up if a person dies it needs to be buried within 24 hours and for someone who is dying and has been in a coma for a long time we are not to keep them in that machines and the family should that person let it go

What restrictions, preferences, beliefs or practices do you have related to conception, pregnancy, birth, or care of babies?

I believe that moms have to have at least 2 years apart of their children, I also believe that if the baby is born that moms should stay with the baby for about a year.

Have you ever received health care from a person(s) of a cultural/ethnic group different than your own? Yes

In terms of your culture and faith practices, how sensitive and knowledgeable do you find your current health care provider? If so, what impact did it have on you?

According to my faith and culture, we clean our self all the time example; washing hands, brushing teeth cleansing after bathroom use, on the other hand, my current health care provider also recommends these things.

What would you like for health care providers who might take care of you or a member of your family in the future to know about your culture, your ethnic group, your religion, and your health beliefs and practices?

I would like my health care provider to know that we believe if a member of my family is sick to seek help from health care providers and also we read the Quran and ask God to restore health.

Your Significant Other (SO) and Friends

If married or in a relationship, recall your answer to the Self Health Assessment questions.

Of what faith, culture, and racial group are your SO? Do similarities and differences in faith, culture, and race present challenges or barriers to your relationship? N/A

How many of your friends are from the same faith, cultural, and racial background as you are (e.g., none, few, some, most, all)? Do similarities and differences in faith, culture, and race present challenges or barriers to your relationships?

All my friends have the same faith, culture, and racial background.

Appendix C
The Genogram.

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