This is an excerpt from Cultural Competence in Sports Medicine by Lorin Cartwright & Rene Shingles.
Inspecting and observing involves looking at the patient's physical structure and body movement to help determine the extent of injury or illness. Skin assessment of patients with dark skin should be done in natural light when possible in order to ascertain the condition; it may be necessary to check mucous membranes, lips, nail beds, palms, and soles of feet for accurate assessment, particularly of jaundice in some Asians and cyanosis in some patients with dark skin. Jaundice may also be observed in African Americans as generalized yellowing of the sclera. Some patients of Mediterranean descent may have blue lips, thus giving a false indication of cyanosis (Campinha-Bacote, 2003). Pallor may present as the absence of red tones in underlying tissue—“brown skin tends to appear yellow-brown and black skin tends to appear ashen” (Salimbene, 2005, p. 40). Sometimes, erythema and ecchymosis may be detected only by palpation—the skin becomes warm to the touch, tight, and edematous in the inflamed area (Campinha-Bacote; Salimbene).
Palpation is a form of touching that is used to medically examine a patient. The purpose is to assess the physical signs of an injury or illness. During palpation, several cultural considerations need to be addressed: space, touch, and expressions of pain.
In U.S. culture, space has been defined in terms of four interpersonal distance zones. The zones are intimate (from contact to 1.5 feet, or about 0.5 meter), personal (1.5 to 4 feet, or 0.5 to 1.2 meters), social (4 to 12 feet, or 1.2 to 3.7 meters), and public (greater than 12 feet, or 3.7 meters) (Hall, as cited in Sue & Sue, 2008). The assessment process necessarily requires the athletic trainer to enter the patient's social, personal, and intimate spaces. The greeting and oral history portions may take place in the social and personal spaces, whereas the observation, inspection, and palpation all occur in the patient's personal and intimate spaces. The athletic trainer should note the patient's level of comfort with the spatial arrangements during the greeting and the taking of the oral history. If the patient continues to lean into the athletic trainer, then he or she typically prefers a smaller distance. In contrast, a patient who steps back or leans away from the athletic trainer may need more distance. The athletic trainer must resist the urge to move away from a patient who is moving in or toward a patient who is moving out. If a patient is uncomfortable with proximity, the athletic trainer should not linger in the intimate space during palpation. To do so may make the patient feel very uncomfortable. The athletic trainer should ask permission to palpate and tell the patient what to expect.
When touching a patient during palpation, the athletic trainer should consider religious and gender issues. The patient's religious or cultural beliefs may dictate that the assessment be performed by an athletic trainer of the same sex. When a health care provider of the same sex is not available, it may be necessary to have another member of the staff or a family member be present during the assessment. When in doubt, ask the patient.
Expressions of Pain
During palpation, the health care provider may purposely elicit pain, and expressions may vary culturally. Some patients may remain stoic because they believe that emotion should be restrained or because they view pain as an inevitability or a fact of life that must be endured. Other patients may express pain emotively or even see the expression of pain as a pain-relieving act. Thus, accurately assessing pain not only involves deciphering an expression of pain but also taking into account nonverbal cues which may provide a better indication of the patient's level of pain.
All patients “deserve a cultural assessment,” not just those who “look” like they need one (Campinha-Bacote, 2003, p. 47). Conducting a culturally based assessment is about establishing a good rapport with the patient. It is about learning what the patient needs—not what the health care provider needs. For example, there is a “direct correlation . . . between patient satisfaction and the amount of time a physician spends with hypertensive African Americans. [Likewise, there was] . . .
increased compliance with nursing interventions among Hispanic and Haitian mothers once the provider explored and demonstrated respect for the client's belief system” (Niemeier, Burnett, & Whitaker, 2003, p. 1243).
Knowledge about variations between groups does not allow one to assume that everyone in a group shares common beliefs, values, and practices. However, knowledge about variations does enhance an athletic trainer's ability to ask better questions and to focus on assessment more effectively (Schim, 2005, p. 256).