{"id":230,"date":"2021-08-28T02:26:26","date_gmt":"2021-08-28T06:26:26","guid":{"rendered":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/chapter\/subjective-assessment\/"},"modified":"2026-03-10T17:33:16","modified_gmt":"2026-03-10T21:33:16","slug":"subjective-assessment","status":"publish","type":"chapter","link":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/chapter\/subjective-assessment\/","title":{"raw":"Subjective Assessment","rendered":"Subjective Assessment"},"content":{"raw":"

Subjective assessment<\/strong> of the respiratory system<\/strong> involves asking questions about the health of the client and symptoms that occur because of pathologies that affect the upper and lower respiratory tract. A full exploration of these pathologies is beyond the scope of this chapter, but common problems associated with the respiratory system include [pb_glossary id=\"574\"]sinusitis[\/pb_glossary], [pb_glossary id=\"576\"]nasal polyps[\/pb_glossary], [pb_glossary id=\"560\"]asthma[\/pb_glossary], [pb_glossary id=\"562\"]pneumonia[\/pb_glossary], [pb_glossary id=\"498\"]cancer[\/pb_glossary], [pb_glossary id=\"570\"]cystic fibrosis[\/pb_glossary], [pb_glossary id=\"564\"]bronchitis[\/pb_glossary], [pb_glossary id=\"566\"]emphysema[\/pb_glossary], [pb_glossary id=\"568\"]chronic obstructive pulmonary disease[\/pb_glossary], and respiratory viruses like [pb_glossary id=\"362\"]<\/strong>coronaviruses[\/pb_glossary]<\/strong> and [pb_glossary id=\"590\"]RSV[\/pb_glossary].<\/span><\/p>\r\n

Common symptoms<\/strong> that can be related to the respiratory system include nasal congestion\/discharge, sinus pain\/pressure, dyspnea, coughing, wheezing, and pain. See Table 1<\/strong> for guidance on subjective health assessment. Many of the questions in this table align with the PQRSTU<\/a> mnemonic. You should consider asking questions in order of importance, thus, you do not follow the sequential order of PQRSTU.<\/span><\/p>\r\n

You should also ask about any medications (prescribed or over the counter) the client is taking: the name, dose, frequency, reason it was prescribed, and how long they have been taking it.<\/span><\/p>\r\n

Remember to always ask questions related to health promotion. Depending on the context of the assessment, you may ask these questions and engage in a discussion during a subjective assessment or after an objective assessment. A section on \u201cHealth Promotion Considerations and Interventions\u201d is included later in this chapter after the discussion of objective assessment.<\/span><\/p>\r\n\r\n

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Knowledge Bites \u2013 Pathophysiology<\/strong><\/h2>\r\n<\/header>\r\n
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Many respiratory-related pathologies are related to inflammatory processes, narrowed airways, and mucous production. These processes cause a variety of symptoms including difficulty breathing, coughing, and noisy breathing. They can also influence the body\u2019s oxygenation and affect a person\u2019s capacity to engage in activities of daily living.<\/span><\/p>\r\n

The SARS-CoV-2 virus (commonly referred to as COVID-19 disease) is a highly infectious virus (emerged in 2019) that affects the lungs and breathing as well as other body systems. It became a pandemic in 2020 because it was highly transmissible and affected people across the globe. It is transmitted through airborne participles and droplets from the mouth and nose when you breathe, talk\/sing\/yell, cough, or sneeze. Video 3<\/strong>\u00a0that will help you understand how the virus affects the lungs in terms of inflammation, fluid accumulation, and lung damage.<\/span><\/p>\r\nVideo 3<\/strong>: How COVID-19 affects the lungs\r\n\r\n \r\n\r\n[embed]https:\/\/www.youtube.com\/watch?v=ZL1z3Uju-I0[\/embed]\r\n\r\n<\/div>\r\n<\/div>\r\n \r\n

Table 1<\/strong>: Common symptoms, questions, and clinical tips<\/span><\/p>\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
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Symptoms<\/strong><\/span><\/p>\r\n<\/th>\r\n

\r\n

Questions<\/strong><\/span><\/p>\r\n<\/th>\r\n

\r\n

Clinical tips<\/strong><\/span><\/p>\r\n<\/th>\r\n<\/tr>\r\n

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Dyspnea<\/strong> refers to difficulty breathing and can be described as shortness of breath, a feeling of breathlessness, not being able to get sufficient air, or being unable to catch your breath.<\/span><\/p>\r\n

The feeling of not being able to catch one\u2019s breath is particularly upsetting because it feels like suffocation.<\/span><\/p>\r\n

When a client is having difficulty breathing, they often also have rapid breathing: [pb_glossary id=\"342\"]tachypnea[\/pb_glossary]. <\/strong><\/span><\/p>\r\n

Older adults sometimes experience mild shortness of breath upon exertion because of the anatomical lung changes including decreased muscle mass, lung elasticity, and increased lung rigidity. This makes it more difficult to breathe and causes the stiffening of lung expansion and recoil, decreased [pb_glossary id=\"364\"]vital capacity[\/pb_glossary]<\/strong>, and increased [pb_glossary id=\"366\"]residual volume[\/pb_glossary]<\/strong>.<\/span><\/p>\r\n<\/td>\r\n

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Do you currently have any difficulty breathing or shortness of breath? Have you recently experienced any difficulty breathing or shortness of breath?<\/span><\/p>\r\n

Remember to incorporate the language that the client uses into your probing.<\/span><\/p>\r\n

Additional probes<\/strong> if the client\u2019s responses are affirmative:<\/span><\/p>\r\n

Quality: What does your difficulty in breathing feel like?<\/span><\/p>\r\n

Provocative\/palliative: Is there anything that makes your breathing worse? Is it worse when you are lying down? Is there anything that makes your breathing better? Does it feel better when you are sitting up?<\/span><\/p>\r\n

Severity: Can you rate your difficulty in breathing on a scale of 0 to 10 with 0 being no difficulty and 10 being the most difficult breathing you have ever had?<\/span><\/p>\r\n

Timing\/treatment: When did the difficulty in breathing begin? What were you doing when it began? Is it constant or intermittent? Do you get short of breath with activity\/exertion? If so, what type of activity? Have you taken anything to treat your difficulty in breathing?<\/span><\/p>\r\n

Understanding: Do you know what is causing the difficulty in breathing?<\/span><\/p>\r\n<\/td>\r\n

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As you are assessing the client, consider raising the head of the bed so that it is easier for them to breathe. However, this decision may be influenced by whether the client\u2019s condition is stable. For example, if the client is showing signs of clinical deterioration and their blood pressure is low, you should lower the head of the bed to increase the amount of blood returning to the heart.<\/span><\/p>\r\n

Use a primary survey approach to determine cues that may indicate clinical deterioration. Assess the client\u2019s respiration rate, work of breathing, oxygen saturation, and then pulse, blood pressure, and temperature, followed by auscultation of lungs.<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

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Coughing<\/strong>, also known as \u201ctussis,\u201d is a common respiratory symptom. It is usually an involuntary reflex involving expulsion of air from lungs or an attempt to clear one\u2019s throat\/breathing passages from foreign bodies, irritants, fluids, and mucus.<\/span><\/p>\r\n

Coughing can be associated with acute or chronic infections or diseases. Coughs can be dry or wet, and wet coughs often produce expectorate (mucus). Mucus can be thin or thick and can be clear, yellow, green, pink-tinged, or bloody. Bloody expectorate is called hemoptysis.<\/span><\/p>\r\n<\/td>\r\n

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Do you currently have a cough or have you recently had a cough?<\/span><\/p>\r\n

If the client\u2019s response is affirmative, begin with an open-ended probe: Tell me about the cough.<\/span><\/p>\r\n

You will probably need to probe<\/strong> further. Additional questions might include:<\/span><\/p>\r\n

Quality: Can you describe the cough? Can you describe what the cough sounds like?(Clients may describe the quality in various ways such as dry, wet, bubbling, barking, or hacking. You can provide examples if they are struggling to find the words). Do you cough anything up? (sputum or phlegm\/mucus). If so, can you describe it? Is it thick or thin? What colour is it?<\/span><\/p>\r\n

Timing\/treatment: When did the coughing begin? Is it constant or intermittent? Have you treated it with anything?<\/span><\/p>\r\n

Provocative\/palliative: Is there anything that makes the coughing worse? Is it worse at a particular time of day? Is there anything that makes it better? Does it feel better when you are sitting up?<\/span><\/p>\r\n

Region: Do you feel the cough is worse in a particular area? (e.g., throat, lungs)<\/span><\/p>\r\n

Severity: Can you rate your coughing on a scale of 0 to 10 with 0 being no coughing and 10 being the worst coughing you have had?<\/span><\/p>\r\n

Understanding: Do you know what is causing the coughing?<\/span><\/p>\r\n<\/td>\r\n

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Until the origin is ruled out, consider it transmissible. Wear eye protection, and you and the client should both wear face masks.<\/span><\/p>\r\n

You should consider raising the head of the bed. A client who is coughing with expectorate might be more comfortable sitting upright.<\/span><\/p>\r\n

Assess the client\u2019s respiration rate, work of breathing, oxygen saturation, and then pulse, blood pressure, and temperature, followed by auscultation of lungs.<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

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Chest<\/strong> and nasal<\/strong> congestion<\/strong> is accumulation of mucus in the chest\/lungs and\/or in the nasal cavity\/nose.<\/span><\/p>\r\n

This congestion may be associated with coughing, runny nose (such as nasal discharge), and sneezing.<\/span><\/p>\r\n<\/td>\r\n

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Do you have any chest or nasal congestion?<\/span><\/p>\r\n

If the client\u2019s response is affirmative, additional probes<\/strong> might include:<\/span><\/p>\r\n

Quality\/quantity: Tell me about it. How bad is it? If there is discharge, what colour is it?<\/span><\/p>\r\n

Timing: When did it begin? Is it constant or intermittent?<\/span><\/p>\r\n

Provocative\/palliative: Is there anything that makes it worse? Is there anything that makes it better?<\/span><\/p>\r\n

Region: Where do you feel the congestion?<\/span><\/p>\r\n

Treatment: Have you treated it with anything? Do you take any medications for it?<\/span><\/p>\r\n

Understanding: Do you know what is causing it or what it is related to?<\/span><\/p>\r\n<\/td>\r\n

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Assess the client\u2019s respiration rate, work of breathing, oxygen saturation, and then pulse, blood pressure, and temperature followed by auscultation of lungs.<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

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Sinus pain\/pressure <\/strong>is a sensation felt in the sinuses. It is commonly associated with inflammation, infection, and\/or blockage of the sinuses.<\/span><\/p>\r\n <\/td>\r\n

\r\n

Do you have any pain or pressure in your sinuses?<\/span><\/p>\r\n

If the client\u2019s response is affirmative, additional probes<\/strong> might include:<\/span><\/p>\r\n

Quality\/quantity: Tell me about it. How bad is it?<\/span><\/p>\r\n

Timing: When did it begin? Is it constant or intermittent?<\/span><\/p>\r\n

Provocative\/palliative: Is there anything that makes it worse? Is there anything that makes it better?<\/span><\/p>\r\n

Region: Where do you feel the pressure\/pain?<\/span><\/p>\r\n

Treatment: Have you treated it with anything?<\/span><\/p>\r\n

Do you take any medications for it?<\/span><\/p>\r\n

Understanding: Do you know what is causing it or what it is related to?<\/span><\/p>\r\n<\/td>\r\n

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Sinus pain can be associated with several other symptoms such as nasal congestion, nasal discharge, headaches, earaches, and pain around the ear and down the neck. It is important to assess the client for any associated symptoms.<\/span><\/p>\r\nThe location of the sinus pain is important to assess to potentially help determine the cause and the sinuses affected.<\/span><\/td>\r\n<\/tr>\r\n

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Wheezing<\/strong> is a whistling sound or noisy breathing associated with inspiration and\/or expiration. It is commonly associated with narrowing of the airways, inflammation, and [pb_glossary id=\"530\"]bronchospasm[\/pb_glossary]<\/strong>.<\/span><\/p>\r\n<\/td>\r\n

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Do you hear any wheezing when you breathe?<\/span><\/p>\r\n

If the client\u2019s response is affirmative, begin with an open-ended probe: Tell me about the wheezing.<\/span><\/p>\r\n

You can probe<\/strong> further with questions related to the PQRSTU mnemonic such as:<\/span><\/p>\r\n

How often does it happen? How bad is it? Is there anything that triggers the wheezing? Do you know what causes it? Is there anything that makes it better? Do you treat it with anything? (e.g., medications, puffers).<\/span><\/p>\r\n<\/td>\r\n

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Wheezing can be associated with an acute or a chronic condition. Some clients can hear it themselves and report it; you might also hear it when you auscultate the lungs.<\/span><\/p>\r\n

If a client is currently wheezing, it is essential to rule out [pb_glossary id=\"524\"]anaphylaxis[\/pb_glossary]<\/strong>, because this is a life-threatening condition. Assess whether the client has allergies and if so, whether they may have been exposed to the allergen. Common allergens related to anaphylaxis are insects (e.g., bees), food, and medications. Related anaphylaxis symptoms might include [pb_glossary id=\"370\"]pruritus[\/pb_glossary]<\/strong>, rash\/hives, difficulty swallowing, swelling of face or lips, and nausea.<\/span><\/p>\r\n

Administration of epinephrine<\/strong> is a priority if anaphylaxis is suspected.<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

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Chest pain<\/strong> associated with the respiratory system can be described in many ways: a sensation in the chest, discomfort, tenderness, tightness, and sharp pain.<\/span><\/p>\r\n

Depending on the etiology, the pain can worsen when breathing and coughing.<\/span><\/p>\r\n<\/td>\r\n

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Do you currently or have you recently had any chest pain or sensations in your chest?<\/span><\/p>\r\n

If the client\u2019s response is affirmative, first ask: Do you have the pain now?<\/span><\/p>\r\n

Additional probes<\/strong> may include:<\/span><\/p>\r\n

Quality\/quantity: Tell me about it. What does it feel like? How bad is it?<\/span><\/p>\r\n

Timing: When did it begin? What were you doing when it began? Is it constant or intermittent?<\/span><\/p>\r\n

Provocative\/palliative: Is there anything that makes it worse? Is there anything that makes it better?<\/span><\/p>\r\n

Region: Where do you feel the pain\/sensation?<\/span><\/p>\r\n

Treatment: Have you treated it with anything? Do you take any medications for it?<\/span><\/p>\r\n

Understanding: Do you know what is causing it or what it is related to?<\/span><\/p>\r\n<\/td>\r\n

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It is important to address any current pain, particularly if it could be of cardiac origin.<\/span><\/p>\r\n

Pain that is associated with the respiratory system can sometimes be relieved by position change. If the client is stable, try sitting them upright. However, if the client is showing signs of clinical deterioration, it is best to position them in supine position and lower the head of the bed in case prompt intervention is needed.<\/span><\/p>\r\n

Assess the client\u2019s respiration rate, work of breathing, oxygen saturation, and then pulse, blood pressure, and temperature, followed by auscultation of lungs.<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

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Other respiratory symptoms<\/strong> can include fatigue, perspiration, confusion, light-headedness, sneezing, sore throat, headache\/body aches, fever\/chills, colour changes in skin\/lips\/nails (such as cyanosis), lymph node swelling, and decreased appetite.<\/span><\/p>\r\n<\/td>\r\n

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Always ask one question at a time.\u00a0Questions might include:<\/span><\/p>\r\n

Have you experienced fatigue? (Or perspiration, confusion, light-headedness, sneezing, sore throat, headache\/body aches, fever\/chills, colour changes of your skin\/lips\/nails such as cyanosis, lymph node swelling, decreased appetite?)<\/span><\/p>\r\n

Use variations of the PQRSTU mnemonic to assess these symptoms further if the client\u2019s response is affirmative.<\/span><\/p>\r\n<\/td>\r\n

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These symptoms can be related to other body systems and non-respiratory issues. It is important to explore these symptoms specifically if the client answers affirmatively to other respiratory-related symptoms.<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

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Personal<\/strong> and family history of respiratory<\/strong> conditions and diseases.<\/span><\/p>\r\n

As noted earlier, common issues associated with the respiratory system include asthma, allergies, pneumonia, bronchitis, emphysema, chronic obstructive pulmonary disease, cancer, cystic fibrosis, and respiratory viruses like corona viruses.<\/span><\/p>\r\n<\/td>\r\n

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Do you have any chronic respiratory conditions or diseases? Do you have a familial history of respiratory conditions or diseases? (e.g., asthma, allergies, emphysema).<\/span><\/p>\r\n

If the client\u2019s response is affirmative, begin with an open-ended probe: Tell me about the condition\/disease?<\/span><\/p>\r\n

If the client has a personal history probing<\/strong> questions might include:<\/span><\/p>\r\n

Timing: When did it occur? When were you diagnosed?<\/span><\/p>\r\n

Quality\/quantity: How does it affect you? What symptoms do you have?<\/span><\/p>\r\n

Treatment: How is it treated? Do you take medication?<\/span><\/p>\r\n

Provocative\/palliative: Is there anything that makes it worse? Is there anything that makes it better?<\/span><\/p>\r\n<\/td>\r\n

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The biological and non-biological nature of family may be important to consider when asking questions: risk factors may be influenced by genetics and\/or culture. Although there may be a genetic role to some respiratory-associated diseases (e.g., asthma, cystic fibrosis), it is more likely that\u00a0 environment and cultural factors like family traditions and practices play a larger role (e.g., lung cancer, emphysema). One example might be living with a smoker.<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n

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Priorities of Care<\/strong><\/h2>\r\n<\/header>\r\n
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It is important to understand which respiratory symptoms are cues that require action. Urgent intervention is required with the following cues: cyanosis\/pallor, new onset confusion, severe shortness of breath or wheezing, or chest pain. All of these can be related to clinical deterioration and hypoxia.<\/span><\/p>\r\n

If cues suggest clinical deterioration, you should ask a colleague to call the physician\/nurse practitioner while you perform a primary survey and a focused objective assessment on the respiratory system. Assess respiration rate, work of breathing, oxygen saturation, and then pulse, blood pressure, and temperature, followed by auscultation of lungs.<\/span><\/p>\r\n

If the client is wheezing, and you think it may be related to a foreign object, quickly inspect the nose and mouth and dislodge it if you can do so simply. For example, young children often put small toys\/objects up their nose; it can become lodged and affect breathing.<\/span><\/p>\r\n

Note that chest pain could be respiratory or cardiovascular related depending on the underlying pathophysiology.<\/span><\/p>\r\n\r\n<\/div>\r\n<\/div>\r\n

Activity: Check Your Understanding<\/span><\/h2>\r\n

[h5p id=\"202\"]<\/span><\/p>","rendered":"

Subjective assessment<\/strong> of the respiratory system<\/strong> involves asking questions about the health of the client and symptoms that occur because of pathologies that affect the upper and lower respiratory tract. A full exploration of these pathologies is beyond the scope of this chapter, but common problems associated with the respiratory system include