Subjective Assessment

Headache is a specific type of pain that can be felt in one certain location or all over the head. It can be described in many ways including sharp, achy, throbbing, full, or squeezing with a viselike quality (a tight, strong, constricting feeling).

Headaches occur when nociceptors react to certain triggers. There are many causes. Although some headaches are related to musculoskeletal injuries, most are neurologically-related and can be related to inflamed or damaged nerves and triggers such as stress, alcohol, lack of sleep, and certain food and medications. Other influences can include muscular tension, dental or jaw problems, infections, and eye problems.

Do you currently have a headache? Have you recently experienced any headaches that you are concerned about? Do you have frequent, severe, and/or recurring headaches that disrupt your day-to-day functioning?

Additional probes if the client’s responses are affirmative may include:

Quality/quantity: What does your headache feel like? How bad is your headache?

Severity: Can you rate your headache on a scale of 0 to 10 with 0 being no pain and 10 being the most pain you have ever had?

Region/radiation: Where do you feel your headache? Does it radiate anywhere?

Provocative/palliative: Is there anything that makes your headache worse? Is there anything that makes your headache better?

Timing/treatment: When did the headache begin? Was it sudden or gradual? What were you doing when it began? Is it constant or intermittent? How often do you get headaches? Have you taken anything to treat your headache? Have you taken any medications?

Understanding: Do you know what is causing the headache? Do other members in your family experience similar headaches?

Other: How does it affect your daily life? 

A severe headache with a quick onset is a cue for concern. This kind of headache can be related to conditions such as stroke. Patients may describe these types of severe headaches as the worst headache they have ever had or say they have never experienced pain like this before.

Chronic headaches can be debilitating for people and affect day-to-day life.
Migraines are a neurological condition. They are often described as throbbing, pulsating, and pounding intense headaches with associated symptoms such as nausea and vomiting, sensitivity to light, noise and smell, and auras. The causes of migraines are not yet clear, but they appear to be linked with genetic, environmental, and hormonal factors. 
  

Paresis, paralysis, and paraesthesia are common symptoms associated with neurological conditions such as stroke or nerve damage.

Paresis is decreased muscle strength of the voluntary muscle groups (often referred to as muscle weakness) whereas paralysis is the inability to move a muscle such as a limb.

Paraesthesia is abnormal sensory sensations such as numbness (loss of feeling), tingling (sometimes described as pins and needles), or other characteristics such as burning and prickling. 

Have you experienced any decrease in muscle strength? (Or inability to move a muscle/limb or abnormal sensations such as numbness or tingling in your face, arm or leg?)

Remember to incorporate the language that the client uses into your probing questions (below, “XX” is used to represent the client’s language).

Additional probes if the client’s responses are affirmative may include:

Timing: Are you currently experiencing XX now? When did it begin? Did it come on suddenly or gradually? Is it constant or intermittent? What were you doing when it began? How often do you get it?

Quality/quantity: What does it feel like? How bad is it?

Severity: Can you rate it on a scale of 0 to 10 with 0 being no XX and 10 being the most XX you have ever had?

Region/radiation: Where do you feel it most? Does it radiate anywhere?

Provocative/palliative: Is there anything that makes it worse? Is there anything that makes it better?

Treatment: Have you taken anything to treat it? Have you taken any medications?

Understanding: Do you know what is causing it?

Other: How does it affect your daily life? 

Falls are a safety concern with paresis, paralysis, and paraesthesia. Fall risk assessment and prevention strategies are essential for client safety. If the client is mobile, strategies may include non-skid shoes or socks, use of prescribed mobility and assistive devices, and removal of hazards in the room. Nurses should consult with occupational therapists and physiotherapists to decrease the client’s risk of falls.

Skin ulcers are another risk factor. Areas of the body that have lost or limited sensation or strength/movement should be assessed daily to decrease further damage to the area. Therefore, it may be important to assess clients using the Braden Scale for risk of pressure sores (see: Skin inspection via Braden Scale).

Paresis, paralysis, and paraesthesia decrease client mobility and therefore increase the risk of blood clots, urinary stasis, decreased peristalsis, and pneumonia. Passive range of motion (ROM) exercises should be performed to encourage continuous movement of the joints and muscles.
Bell’s palsy is a facial nerve (CN VII) disorder causing temporary paralysis of the face in which it droops downwards (e.g., eye, cheek, mouth). However, similar symptoms can occur with Botox and other facial fillers/injections. A thorough assessment can help determine the origin of the cause. 

Dysphagia and dysarthria are common symptoms associated with various neurological conditions such as stroke, brain tumour, and neurodegenerative diseases (e.g., Alzheimer’s, multiple sclerosis, Parkinson).

Dysphagia is impairment in swallowing. Clients often refer to it as difficulty or trouble swallowing and it is sometimes associated with pain.

Dysarthria is a neuromotor impairment in speaking: clients may have difficulty saying or forming a word and may have reduced strength and speed when speaking. This can result in slow or slurred speech.

Have you experienced any difficulty swallowing? Have you experienced any difficulty speaking?

Remember to incorporate the language that the client uses into your probing questions (remember that below, “XX” refers to the client’s language).

Additional probes if the client’s responses are affirmative may include:

Timing: Are you currently experiencing XX now? When did it begin? Did it come on sudden or gradual? Is it constant or intermittent? What were you doing when it began? How often do you get it?

Quality/quantity: What does it feel like? How bad is it?

Severity: Can you rate it on a scale of 0 to 10 with 0 being no XX and 10 being the most XX you have ever had?

Region/radiation: Where do you feel it most? Does it radiate anywhere?

Provocative/palliative: Is there anything that makes it worse? Is there anything that makes it better?

Treatment: Have you taken anything to treat it? Have you taken any medications?

Understanding: Do you know what is causing it?

Other: How does it affect your daily life?

New onset of dysphagia requires immediate action because it can be associated with conditions such as stroke and can lead to clinical deterioration as well as other complications such as choking or aspiration pneumonia. Always notify the physician or nurse practitioner. Additionally, if the client is experiencing new onset dysphagia, it is important to restrict food or fluids until this has been fully assessed. If possible, have the client sit upright (e.g., High Fowler’s position) or raise the head of the bed.

After any acute symptoms have been managed, consult with a speech language pathologist and dietician to discuss safety measures required during meal assistance to decrease risk of choking and aspiration pneumonia. Dysphagia management tips may include a special dysphagia diet, having the client sit upright, placing food on the noneffective side of the mouth, use of thickening fluids, and taking small bites.

Dysarthria can cause slowed, slurred speech, which may be misdiagnosed as intoxication. A thorough assessment is required to determine the cause of dysarthria to ensure proper interventions are performed. Evaluating a client’s speech, including changes in speech, is part of the primary survey assessment. Consult with a speech-language therapist on exercises to strengthen speech-related muscles and use of other communication aids. 

Visual impairment is a disturbance in the client’s ability to see. Symptoms may include blurred vision, double vision, or partial or complete vision loss (central or peripheral) in one eye or both, dark area in the visual field, shadowed vision, and/or light sensitivity. 

Have you experienced any difficulty seeing or new changes to your sight? (You may choose to provide some examples.)

Remember to incorporate the language that the client uses into your probing questions (remember that below, “XX” refers to the client’s language).

Additional probes if the client’s responses are affirmative may include:

Timing: Are you currently experiencing XX now? When did it begin? Did it come on sudden or gradual? Is it constant or intermittent? How often do you get it?

Quality/quantity: What does it feel like? How bad is it?

Severity: Can you rate it on a scale of 0 to 10 with 0 being no XX and 10 being the most XX you have ever had?

Region/radiation: Where in your eye do you experience it?

Provocative/palliative: Is there anything that makes it worse? Is there anything that makes it better?

Treatment: Have you taken anything to treat it? Have you taken any medications?

Understanding: Do you know what is causing it?

Other: How does it affect your daily life?

A sudden change in vision is a priority in care. This cue is considered an emergency and needs immediate action. Sudden vision change could indicate a stroke and blood clot in the retinal artery. Immediate care is required to decrease the risk of permanent vision loss (blindness). 

Dizziness, balance issues, and incoordination are neurological symptoms that are sometimes, but not always, associated with each other.

Dizziness refers to impaired spatial orientation in which clients describe feeling light-headed, woozy, or that they might faint. It may be associated with nausea and syncope. (Vertigo is often described as dizziness, but vertigo is actually a different neurological symptom in which the client feels like they are spinning or the environment around them is spinning.)

Balance issues are associated with feeling unsteady: the client feels like they may lose their balance or fall down. It can sometimes be associated with dizziness.

Incoordination refers to loss of muscle control and lack of coordination such as the impaired ability to use parts of the body together (e.g., hands, arms, legs). It may result in impaired ability to walk smoothly or to use arms/hands together.

Have you experienced any dizziness or a feeling of light-headedness? 

Remember to incorporate the language that the client uses into your probing questions (remember that below, “XX” refers to the client’s language).

Additional probes if the client’s responses are affirmative may include:

Quality/quantity: What does XX feel like? Have you ever passed out or lost consciousness? How bad is it?

Timing: Are you currently experiencing it now? When did it begin? Is it constant or intermittent? What were you doing when it began? Is it associated with position changes such as standing up? How often do you get it?

Severity: Can you rate it on a scale of 0 to 10 with 0 being no XX and 10 being the most XX you have ever had?

Provocative/palliative: Is there anything that makes it worse? Is there anything that makes it better?

Treatment: Have you taken anything to treat it? Have you taken any medications?

Understanding: Do you know what is causing it?

Other: How does it affect your daily life?

Fall risk assessment is essential to help the client take precautions against falling. As per the Canadian Institute of Patient Safety (2015), think about the SAFE mnemonic:

Safe environment (e.g., well-lit environment, remove tripping hazards).

Assist with mobility, including balance and transfers (e.g., if relevant, ensure mobility aids [cane, walkers], assistive devices [bars, eyeglasses, hearing aid], and assist client as needed).

Fall risk reduction (e.g., non-slip footwear, bed in lowered position, call bell in reach).

Engage the client and family (e.g., having conversations about risk factors and prevention).

Various fall assessment tools are available to help you systematically assess risk factors related to falls. These factors may include a history of falls/near falls, acute condition, ability to move around, mobility aids, or hearing, vision, or cognitive impairment. If the client has already been assessed, you should follow all recommendations, as well as all institutional policies to prevent falls.

Seizures are sudden changes in the brain’s electrical function that affect consciousness, muscle tone, movement, and sensations. For example, a client may be unable to move or walk, or may blink repeatedly, stare with no movement of eyes, experience stiffening and spasms of the muscles, loss of muscle tone, or exhibit sudden repetitive movements often described as twitching or jerking.

Tonic-clonic seizures refer to seizures in which a client’s muscles stiffen and twitch. In contrast, a client experiencing an absence seizure often stares off into space and/or repeatedly blinks.

After the active (ictal) phase, many clients experience a recovery (postictal) phase that typically last minutes to 30 minutes (but for some this period may last for days), with symptoms including sore muscles, fatigue, confusion, and headache.

The cause of a seizure may be unknown, or a result of a head injury, infection, high fever, certain medications, electrolyte imbalance, or other diagnosis/illness. A client who has two or more seizures is often diagnosed with epilepsy. 

Have you experienced a seizure?

Remember to incorporate the language that the client uses into your probing questions.

Additional probes if the client’s responses are affirmative may include:

Quality/quantity: What does it feel like or look like? Have you ever lost consciousness? How bad is it?

Timing: When did you experience one last? How often do you experience them? At what age did you experience your first one?

Provocative/palliative: Is there anything that makes it worse? Is there anything that makes it better?

Treatment: Have you ever sought treatment for it? Have you taken anything to treat it? Have you taken any medications?

Understanding: Do you know what is causing it?

Other: How does it affect your daily life? Has anyone ever told you that you have short episodes where you stare off into space or repeatedly blink?

Seizures can last a few seconds to many minutes or longer. In some institutions, seizures are treated when they last longer than 3 minutes or the client has 3 within 30 minutes. 

Seizures can place the client in danger and safety precautions need to be considered. The client could be at risk of falling, accidents in the workplace (e.g., machinery), and pregnancy complications due to medications. Encourage clients to wear a medical alert bracelet.

As per the Canadian Epilepsy Alliance (n.d.), when a client has a seizure:

• Stay with them and call for help.
• Roll them onto their side.
• Place a pillow under their head.
• Clear the surrounding area of hazards. 
• Do not restrain the client or place anything in their mouth.
• Record the time, duration, and symptoms. 

Consider the client’s own unique plan to manage their seizures.

Other neurological symptoms can include fatigue, tremors, fasciculations, confusion, hearing impairment, difficulty breathing, and nausea and vomiting.

For example, tremors can be related to neurological diseases (e.g., Parkinson’s disease) or other factors such as caffeine, certain medications, or overactive thyroid. 

Always ask one question at a time. Questions might include:

Have you experienced tremors or twitching like movements? (Or confusion, fatigue, hearing impairment, difficulty breathing, or nausea and vomiting?)

Use variations of the PQRSTU mnemonic to assess these symptoms further if the client’s response is affirmative.

These symptoms can be related to the neurological system as well as other body systems. It is important to explore these symptoms specifically if the client answers affirmatively.

Personal and family history of neurological conditions and diseases.

As noted earlier, common issues associated with the neurological system include stroke, migraines, seizures, dementia, Parkinson’s disease, multiple sclerosis, or other movement disorders.

Do you have any chronic neurological conditions or diseases? Do you have a familial history of neurological conditions or diseases? (Give examples).

If the client’s response is affirmative, begin with an open-ended probe: Tell me about the condition/disease?

Remember to incorporate the language that the client uses into your probing questions.

If the client has a personal history, probing questions might include:

Timing: When were you diagnosed?

Quality/quantity: How does it affect you? What symptoms do you have?

Treatment: How is it treated? Do you take medication?

Provocative/palliative: Is there anything that makes it worse? Is there anything that makes it better?

Risk factors may be influenced by genetics and/or culture, so you should ask about the biological and non-biological nature of family.

Some neurological-associated diseases (e.g., Parkinson’s) are related to genetics, but it is more likely that environmental and cultural factors (such as family traditions and practices) play a larger role. Examples might include diet, sedentary lifestyle, and smoking.