1. 1. Lan Vu Aimie Terry Sharon Kim Sherwin Ybera NUR 312 2014
2. 2. Introduction
3. 3. Basic World View Collectivist God guides life Patriarchal Women are expected to be submissive to men. High level of respect for elders, health-care providers, and religious leaders. Hot and Cold therapy Value education Extended family serves as a support system. (Purnell, 2013).
4. 4. Geographic Origins Inhabited by Tano Indians Found by Columbus during his second voyage to America. Ruled by Spain for over 400 years. Numbers of residents decreased due to infectious diseases and warfare. Became possession of U.S in 1898 after Spanish-American war. Jones Act of 1917 all Puerto Ricans became U.S. citizens. (Purnell, 2013).
5. 5. Current Life in America Over 3 million living in U.S. Many reside in Connecticut, Florida, Illinois, and New York. (Purnell, 2013). 28% high school diploma 29% work in sales and office occupation (Centers for Disease Control and Prevention, 2013). 28% live in poverty Annual income is $25,000 a year 12% unemployment rate (U.S. Census Bureau, as cited by Brown, 2013).
6. 6. Beliefs Related to Individuals Collectivism is highly valued by this cultural group Children are the center of the family Familism-social pattern in which family tradition assumes a superior position over individual rights and interest (Purnell, 2013). Value the unity of family Women are considered the main caregivers Female mothers tend to be protective of their children and may use physical punishment. (Purnell, 2008).
7. 7. Beliefs Related to Family Most families expect their children to stay at home until married or expected to pursue college. Male children are taught to be powerful and strong, domineering over women. Female children are taught to assume the roles of motherhood, home economics and family dynamics which gives them a powerful social status. Elderly tend to live with their children and be cared for financially and emotionally (Purnell, 2013)
8. 8. Beliefs Related to Family Continued Elderly see placement in a nursing home as inconsiderate. Family members are expected to be at the bedside of the ill. Taboo related to Homosexuality (Purnell, 2013). Personalismo in this culture is highly valued Health and disease may be deemed consequences of Gods approval or disapproval of a persons behavior (Chong, 2002).
9. 9. Health Care Practices Have a curative view of health Puerto Ricans tend to underuse health promotion and preventive services Use emergency health care services for acute problems Good hygiene is a basic concept of health promotion Folk and traditional practices o Espiritistas - communicate with spirits o Santeria focus on health promotion Botanicas folk religious store Family members- source of support and care (Purnell, 2013).
10. 10. Health Care Practices cont. May be loud and outspoken in expressing pain Mental illness carries a stigma Organ donation is seen as an act of good will and gift of life Autopsy may be seen as a violation of the body May have a gender or age bias against Health Care Providers (HCP) HCP seen as a wise authority figures Barriers to health care Insurance Lack of access Poor English-language skills Low acculturation Poor socioeconomic status Lack of transportation (Purnell, 2013).
11. 11. Health Care Practices cont. High Risk Behavior Leading Cause of Death Alcoholism Marijuana Tobacco Cocaine Lack of condom (Chong, 2002). Heart disease Cancer HIV Accidents Homicide (Centers for Disease Control and Prevention, 2013).
12. 12. Health Care Practices cont. Beneficial practices: rubbing the stomach or back gently with cooking oil for empacho (Centers for Disease Control and Prevention, 2013). cold condition is treated with hot medication and vise versa Use tea from alligators tail, snails, or savila (plant leaves) for asthma and congestive heart failure Also use boiled mint, tea, or lemon tree tea Neutral practices: Fanning the face or blowing into the patients face is believed to provide oxygen and relieve dyspnea Dysfunctional practices: Alcolado (smelling or rubbing isopropyl alcohol) alleviate nausea and vomiting (Purnell, 2013).
13. 13. Food Preferences and Traditions Common Food: Fritters, pastas, breads, crackers, vegetables, and fruits. Favorite side dish: Tostones, fried green or ripe plantains Most common viandas (roots vegetable) : celery roots, sweet potatoes, dasheens, yams, breadfruit, breadfruit, breadnut, green and ripe plantains, green bananas, tanniers, cassava, and chayote squash or christophines (Purnell, 2013).
14. 14. Food Rituals Traditional Puerto Rican Families usually begin their day with a cup of coffee or caf con leche (coffee with milk) such as espresso with lots of sugar before breakfast. Many family introduce children to coffee as early as 5 or 6 years of age. A traditional Puerto Rican breakfast: oatmeal, cornmeal, rice, wheat cereal cooked with vanilla, cinnamon, sugar, salt and milk. Lunch (noon) and dinner ( 5:00 or 6:00p.m.) A cup of espresso-like coffee served : 10:00 a.m. and 3:00 p.m. (Purnell, 2013).
15. 15. Food Preferences and Traditions Main dishes: Rice and stew habichuelas (beans), served as many as 12 side dishes. Consider complete meal: rice cooked with vegetable or meat (Purnell, 2009, p. 415). Seasonings for rice stew (guisado) : sofrito (cilantro, recao, onions, green peppers, and other non spicy ingredients. Traditional holiday dish : rice with gandules , pernil asado-pork, pasteles- root vegetable, green plantain, bananas, or condiments filled with meat and wraped with platain leaves (Purnell, 2013).
16. 16. Hot-Cold Classification Hot Illnesses: Include: GI diseases (constipation, diarrhea, Crohns colitis, ulcer; bleeding) pregnancy, menopause, rashes, acne, headaches, heart disease; urological illnesses. Treated with: cocoa products, alcoholic beverages, caffeine products, hot cereals from wheat and corn, salt, spices and condiments, beans, nuts and seeds. Cold Illnesses: Include: Osteomuscular disease (arthritis, rheumatoid arthritis, multiple sclerosis), menstruation, respiratory illnesses. Treated with: rice, milk, barley water, sugar, root vegetables, avocado, fruits, vegetables, white meat, honey, onions (Purnell, 2013).
17. 17. Dietary and Health Practices Menstruation Foods taboo: Avoid spices, cold beverages, acid-citric fruits and substances, chocolate and coffee. Foods encouraged: Plenty of hot fluids, such as cinnamon tea, milk with cinnamon and sugar, teas such as chamomile, anise seed, linden tea, mint leaves Health practices: Avoid exercise and practice good hygiene, Do not walk barefoot. Avoid wind and rain, Stay as warm as possible Pregnancy Foods taboo: Avoid hot food, sauces, condiments, chocolate products, coffee, beans, pork, fritters, oily foods, and citric products. Foods encouraged: Milk, beef, chicken, vegetables, fruits, ponches. Health practice: Rest and get plenty of sleep. Eat plenty of food. Follow diet cautiously. Many avoid sexual intercourse early in pregnancy. Practice good hygiene and take warm showers. Lactation Foods taboo: Avoid beans, cabbages, lettuce, seeds, nuts, port, chocolate, coffee, and hot food items at all at times. Foods encouraged: Milk, water, ponches, chicken soup, chicken, beef, pastas, hot cereals. Health practice: Avoid cold temperatures and wind. A few may avoid showering for several days during the cuarentena after birth. Great attention is paid to health of the mother. Infant feeding Food taboo: Avoid beans, too much rice, and uncooked vegetables (Purnell, 2013)
18. 18. Dietary Practices for Health Promotion Infancy mothers tend to feed cows milk, canned milk, or evaporated milk earlier than recommended. A baby, who is a little fat, gordito, and a red cheek is seen as healthy. Iron is considered as a hot food that is not usually taken during pregnancy. Educating women about the importance of maintaining to take daily iron supplement, even during pregnancy and lactation. Elderly fresh squeezed orange and grape juices and punches are used as a nutrition support in immune-suppressed or ill elders. Brandy may be added to black coffee for individuals who have low blood pressure and are weak. (Purnell, 2013) Most common herbs used by Puerto Rican women: black cohosh, evening primrose, St. Johns wort, gingko, ginseng, valerian root, sarsaparilla, chamomile, red clover, and passionflower (Purnell, 2009).
19. 19. Traditions El Dia de Reyes (Three Kings Day) Domingo de Ramos (Hede, 2013)
20. 20. Education Children are praised and encouraged to become educated Educational system is similar to the mainland US for all educational levels, nevertheless, when migrated to mainland Literacy level is 94% both men and women Universidad (university) refer to 4-years college institution Agriculture as the primary locus of economic activity and income Sugar production as main source of income in agricultural sector High school completion rates are only 76.6% and a college degree is only 16.5% (Purnell, 2013).
21. 21. Religion/Spirituality Roman Catholic predominant religion (85%) o Influence approach in health and illness Espiritistas- communicate with spirits to promote spiritual wellness and treat mental illness Use azabache (small black fist) or Rabbits foot for good luck Use Rosary beads and patron saint figure from outside evil sources (Purnell, 2013).
22. 22. Religion/Spirituality cont. Fertility practices o Teenage pregnancy due to culturally imposed male behaviors and lack of parental guidance or supervision o Use of birth control methods is seen to be immoral because of Catholic church o Rhythm methods and abstinence is accepted o Fertility control methods used are: tubal ligation also called La Operacion (the surgery), oral contraceptives, hysterectomies, and oophorectomies o Refrain from tener relaciones ( sexual intercourse ) on first trimester o Wish to have their bodies covered and limited number of internal examinations for labor o Cuarentena avoiding cold and hot temperature and rest for 40 days. o 10 to 11% of Puerto Rican women breastfeed (Purnell, 2013).
23. 23. Religion/Spirituality cont. Death Rituals o News about deceased should be given first to the head of the family o it is important to extend burial rituals until all close family members are present o Expressing themselves through loud crying and verbal expressions of grief is culturally acceptable o Ataque de nervios hearing about the death of the loved ones (Purnell, 2013).
24. 24. Community Women viewed as: central role in the family and the community, and the family is moving toward more egalitarian relationships. Priority over work: family responsibilities, pregnancy, and the health of their children and other family members. Puerto Ricans celebrate, mourn, and socialize around food. Food is used: 1) To honor and recognize visitors, friends, family members, and health-care providers 2) As an escape from everyday pressures, problems, and challenges 3) To prevent and treat illnesses (Purnell, 2009).
25. 25. Communication Dominant Language and Dialects Puerto Rico was the only Spanish speaking Latin American country in which children beginning in kindergarten, learned to read and write English and Spanish (Purnell, 2013). Forced to learn English after the U.S. occupation in 1898. Language is political issue. Use standard form of Spanish, no dialects used. Common expression of astonishment, surprise, lament, or pain phrased as: !Ay bendito! English and Spanish are both official languages. Speech style: melodic, high-pitched, fast rhythm that may leave health-care providers confused. This pitch and these inflections applies when speaking English. Feeling insulted if people comment on their accent. The healthcare provider should avoid making comments about accent, use caution when interpreting voice pitch, and seek clarification when in doubt about the content and nature of a conversation that may seem confrontationa (Purnell, 2009).
26. 26. Cultural Communication Patterns Many individuals share sensitive information, options, and decisions with close family members. Verbal approval by: extended family or community member who are knowledgeable in health matter. Ask if verbal approval or consent from the partner should be obtained first if a consent is needed from a woman. Clarification of the information, language preference: verbal and written Allow time for the exchange of information when critical decisions need to be made. Value: simpatia, likeable, attractive, and fun-loving. If confianza (trust) established, health-care providers can establish open communication with a person and families (Purnell, 2009).
27. 27. Touch, Space, Eye Contact, Body Language, Modesty Acculturated and those born in the U.S., eye contact is supported and is often encouraged. Women greet those who are familiar, with a strong hug Women greet family and friends with a strong hug and a kiss. Men may greet men with a strong right handshake and use the left hand to stroke the greeters shoulder (Purnell, 2008). Modesty is highly valued.
28. 28. Concept of time Have comparative views of time but do not feel regular attendance and being on time is of importance (Purnell 2013). May interfere with being on time for appointments. present-oriented External locus of control Reliance on God Coping mechanisms
29. 29. Format for Names Greet clients with Seor, Seora, Doa or Don unless otherwise directed. Single women prefer to use father and mothers surname Married women keep the fathers surname and take on husbands last name with de in between the two.
30. 30. Gender Roles Males are expected to support the family financially in traditional families. Decision makers. Females are expected to respect and obey the men and to raise and discipline children. Will gain status as they become older. If both parent work, grandparent will take over role in rearing grandchildren. Male children are raised with a macho behavior Dominance over women, pursuit high-paying jobs Female children are raised to focus on home economics and motherhood. Children are to follow family traditions, get education, and respect their elders and persons with high-status. (Purnell, 2013).
31. 31. Genetic Characteristics (biocultural ecology) Mixture of Native Indian, African, and Spanish. Skin color varies from light to dark Anemia and jaundice are more difficult to assess in darker skin tones. Mongolian spots are commonly seen on newborns and infants. Hispanics need lower doses of antidepressants and experience more side effects. (Zoucha & Zamarripa, 2013)
32. 32. Common Diseases Leading causes of death: heart disease, malignant neoplasms, diabetes mellitus, and AIDS. Decrease mortality rates: lung, breast, and ovarian cancers. Increased incidence of stomach, prostate, esophageal, pancreatic, and cervical cancers. High incidence of: cardiopulmonary and osteomuscular diseases for elderly. Dengue fever from Aedes aegypti mosquito Highest HIV incidence than other ethnic groups. (Purnell, 2013).
33. 33. Drug Metabolism No information on differences in drug metabolism African heritage: Need higher doses of immunosuppressants Respond poorly to beta blockers Higher rate of angioedema with ACE inhibitors Some Puerto Ricans are short in stature, have higher subscapular and tricep skin folds, long trunks, and short legs. Caution for therapeutic dosages. (Purnell, 2013).
34. 34. Nurses can provide culturally sensitive nursing care by Developing mechanisms to integrate individual, family, and community resources. Offer weekend, evening, and late-night health-care services in community based setting. Incorporate the participation of the family in the care of the ill. Inquire about practices and encourage patients to bring their medications every visit. Acknowledge and incorporate traditional healing practices into treatment regimen.
35. 35. What can be done to enhance understanding regarding hospital stay, surgery, medications, diet, medical treatment? Use videos and literature in Spanish and with pictures of Hispanics to help increase compliance with health interventions (Purnell, 2009). Use appropriate pain scale. Provide interpreter in all points of contact. Discuss clients use of folk remedies to make sure they do not conflict with current medical orders. Become familiar with food practices when planning culturally congruent dietary alternatives (Purnell, 2013).
36. 36. What nurses can do to form positive relationship Incorporate the concept of personalismo. Engage in a friendly conversation. Develop a trusting relationship. Communicate with client using a soft tone of voice. Project a professional image. Discuss and incorporate their ethic folk practices that are beneficial or neutral into their care. Assess clients religious practices and permit access to religious leaders (Purnell, 2013).
37. 37. Recommendations for future research Find out barriers that Puerto Rican clients face while receiving health care. Promoting tobacco cessation to help decrease asthma disparities in Puerto Rican children.
38. 38. References Brown, A. (2013). Hispanics of Puerto Rican Origin in the United States. Retrieved from http://www.pewhispanic.org/2013/06/19/hispanics-of- puerto-rican-origin-in-the-united-states-2011/. Centers for Disease Control and Prevention. (2013). Cultural Insights: Communicating with Hispanics/Latinos. Retrieved from http://www.cdc.gov/healthcommunication/Audience/ AudienceInsight_CulturalInsights.pdf Chong, Nilda, (2002). The Latino patient: a cultural guide for health care providers. Yarmouth, ME: Nicholas Brealey Publishing. Purnell, L. D. (2008). People of Puerto Rican Heritage. In L.D. Purnell and B. Paulanka (Ed.), Transcultural Health Care: A culturally competent approached (3rd ed., pp. 395- 396). Philadelphia: F. A. Davis.
39. 39. References Purnell, L. D. (2009). People of Puerto Rican Heritage. In L.D. Purnell (Ed.), Guide to culturally competent care (2nd ed., pp. 321-342). Philadelphia: F. A. Davis. Purnell, L. D. (2013). People of Puerto Rican Heritage. In L.D. Purnell (Ed.), Transcultural Health Care: A culturally competent approached (4th ed., pp. 407-425). Philadelphia: F. A. Davis. Hede, M. (2013). The most important Puerto Rican Holidays. Retrieved from: http://hispanic-culture-online.com/puerto- rican-holidays.html Zoucha, R, & Zamarripa, C. A. (2013), People of Mexican heritage. In L. D. Purnell (Ed.), Transcultural health care: A culturally competent approach, (4th ed., pp. 364-365). Philadelphia: F. A. Davis.