14.3 Subjective Assessment

Dysphagia is difficulty related to swallowing and can involve difficulty related to swallowing saliva, food, and/or fluids. It can be caused by a variety of conditions and can be associated with structural issues (inflammation) or neural issues (stroke).

Do you have any current or recent difficulty swallowing?

If the client’s response is affirmative, additional probes may include:

Quality/quantity: Tell me about the difficulty. What does if feel like? How bad is it?

Region: Where do you feel it (e.g., in the throat area or lower in the upper esophageal area)?

Understanding: Do you know what is causing it? Do you have any related symptoms (e.g., pain, swollen glands, excessive saliva, drooling)?

Timing: When did it begin? What were you doing when it began? Is it constant or intermittent?

Provocative/palliative: Is there anything that makes it worse? Is it aggravated or associated with eating or drinking? Is there anything that makes it better (e.g., position)?

Treatment: Have you treated it with anything? Do you take any medications for it?

New onset of dysphagia requires immediate action because it can lead to clinical deterioration and complications such as choking or aspiration pneumonia. If a client is experiencing new onset dysphagia, it is important to restrict food or fluids until it has been fully assessed. If possible, have the client sit upright (e.g., high Fowler’s position) or raise the head of the bed.

Oral lesions, discolorations, and bleeding gums.

Do you currently have or have you had any chronic issues with sores/ulcers in your mouth, discoloration of your mouth, or bleeding gums?

If the client’s response is affirmative, additional probes may include:

Region: Where is it located?

Quality/quantity: Tell me about it. How bad is it?

Timing: When did it begin? What were you doing when it began? Is it constant or intermittent?

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

Treatment: Have you treated it with anything? Do you take any medications for it?

Understand: Do you know what is causing it or what it is related to?

The first action is to inspect the mouth so that you can provide an objective assessment.

Interventions will depend on the cause. For example, bleeding gums may be caused by brushing too hard or increased vascularity associated with pregnancy; they can also be caused by gum disease, so you may need to refer the client to a dentist.

Xerostomia is dry mouth; it can be mild and easily treated or severe and affecting a client’s quality of life, health, and overall well-being. It can be associated with dehydration, certain medications, cancer treatments such as radiation therapy, and alcohol and drug use.

Do you currently have a dry mouth or have you had any chronic issues with dryness in the mouth?

If the client’s response is affirmative, additional probes may include:

Quality/quantity: Tell me about your dry mouth. What does it feel like? How bad is it?

Timing: When did it begin? Is it constant or intermittent?

Understanding: Do you know what is causing it or what it is related to?

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

Other questions may include: How much fluid do you drink per day? Are you taking any medications or radiation therapy? How much alcohol do you drink per day? Do you take any drugs? Do you smoke?

Treatment: Have you treated it with anything? Do you take any medications for it? Tell me about how much fluid you drink per day.

Interventions will depend on the cause.

Older adults are at risk for xerostomia due to decreased intake of fluids as well as increased usage of medications and certain medical conditions that affect the functioning of the salivary glands.

It may be as simple as encouraging the client to drink more water, limit sodium, limit alcohol and drug use, and use sugar-free gum or lozenges.

You should also ask about smoking, which can further aggravate symptoms related to dry mouth.

If a client has chronic dry mouth, inspect their mouth for associated symptoms such as cracked lips, gum disease, tooth decay, and oral lesions. You should also assess whether it is affecting the client’s nutrition or other elements of daily life, such as wearing dentures, especially when the client is an older adult.

Mouth pain or sensitivities can involve a sore throat, tooth pain or sensitivities, and jaw pain.

Do you currently have or have you had any issues with mouth pain or sensitivities such as a sore throat, tooth pain or sensitivities, or jaw pain?

If the client’s response is affirmative, additional probes may include:

Region: Where is it located?

Quality/quantity: Tell me about it. How bad is it?

Timing: When did it begin? What were you doing when it began? Is it constant or intermittent?

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

Treatment: Have you treated it with anything? Do you take any medications for it?

Understand: Do you know what is causing it or what it is related to?

These symptoms require an objective assessment to assess further GI signs, or signs related to other systems.

First, assess whether the jaw pain might be cardiac-related. Angina is a critical finding that requires immediate intervention and can radiate to the jaw area. In order to determine this, you should assess what brought the pain on. For example, was there a physical injury? If not, are there other related factors and symptoms?

Another common cause of jaw pain is bruxism, which can be caused by stress. These types of symptoms and tooth pain and sensitivities usually require referral to a dentist.

Upper and lower GI pain can be associated with many conditions. This is an unpleasant sensation that is described subjectively in various ways, such as tenderness, achy, discomfort, burning, or sharp pain.

Do you have any current or recent pain in the esophageal or abdominal region (or unpleasant sensations such as tenderness)?

If the client’s response is affirmative, additional probes may include:

Region: Where do you feel the pain/sensation? Does it radiate anywhere?

Quality/quantity: Tell me about it. What does it feel like? How bad is it?

Timing: When did it begin? What were you doing when it began? Is it constant or intermittent?

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

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

Treatment: Have you treated it with anything? Do you take any medications for it?

Understand: Do you know what is causing it or what it is related to?

With children, always tailor questions to their developmental stage. With infants and pre-verbal or nonverbal children, you may need to focus on objective assessment such as behavioral and physiological signs of pain.

Remember that GI pain is sometimes cardiac-related (angina). You must rule out this possibility because it can be a critical finding that requires urgent intervention.

Nausea and vomiting (emesis) are common symptoms associated with many conditions. Nausea is an uneasiness/queasy feeling in the stomach associated with the urge to vomit. Vomiting (emesis) is the emptying of the GI tract (usually the contents of the stomach/esophagus) through the mouth. When associated with pregnancy, this is called hyperemesis gravidarum (morning sickness).

Do you have any current or recent nausea and vomiting?

If the client’s response is affirmative, additional probes may include:

Timing: When did it begin? When was the last time? What were you doing when it began? Is it constant or intermittent? Is it associated with eating?

Quality/quantity: Tell me about it. What does the nausea feel like? How bad is it?

If the client indicates vomiting, ask: How much do you vomit? Is it undigested food? What color is it? Is there blood in it?

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

Treatment: Have you treated it with anything? Do you take any medications for it? (If so, do they help?)

Understand: Do you know what is causing it or what it is related to? Do you have any other related symptoms (e.g., stomach pain, fever)?

Nausea and vomiting are usually not serious, and are often associated with a bacterial or viral infection. However, they may be associated with a more serious condition such as appendicitis, a concussion, or an intestinal blockage.

Hematemesis is a serious concern that suggests GI bleeding. It is important to assess the color, as this can help determine where the bleeding is coming from and whether it is active bleeding or old, dried blood. For example, bright red suggests active bleeding from the upper GI system. You might also visualize vomit that has dark brown or black specks in it resembling coffee grounds, which is suggestive of bleeding.

It is important to determine the cause and severity of the nausea and vomiting. Antiemetics are a class of drugs used to prevent and treat nausea and vomiting. Many types are available, including dimenhydrinate (Gravol).

Assess the client for risk of dehydration, particularly among children or older adults or when vomiting is frequent with large quantities. Common signs of dehydration include dry mouth, cracked lips, decreased skin turgor, tachycardia, increased thirst, decreased urine output, delirium, and in infants, sunken fontanelles.

Changes in bowel patterns can include constipation or diarrhea. These changes can be short-term or chronic and can be associated with many health conditions and other factors such as diet.

Constipation refers to decreased frequency in bowel movements (BMs) (fewer than three per week) and difficulty having a BM (having to strain to push stool out, hard stool). Diarrhea refers to soft, loose, watery stools that are not formed and are frequent (three or more a day).

Tell me about your normal bowel patterns.

Probing questions may include: How often do you have a bowel movement? What is the consistency (soft or hard)? What color is it? Have you ever noticed mucus or blood in it? Do you have any concerns about your bowel patterns? Do you take any medications to help you have a bowel movement (such as a stool softener or laxative)? Have you had any recent or frequent diarrhea or constipation?

If the client has concerns about their bowel patterns or has reported a problem such as diarrhea or constipation, probe further with questions such as:

Timing: When did it begin? When was the last time? Is it constant or intermittent? Is it associated with eating?

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

Treatment: Have you treated it with anything? Do you take any medications for it (if so, do they help)?

Understand: Do you know what is causing it or what it is related to? Do you have any other related symptoms (e.g., stomach pain)?

Remember that normal bowel patterns vary from client to client.

Some people, particularly older children/adolescents and young adults, may feel embarrassed to talk about bowel patterns. Try to normalize the discussion using statements like “I like to speak with all clients about their bowel patterns because it can provide information about your health.”

An inclusive approach to assessment involves age- and culturally-appropriate terms. For example, not everyone will know what a BM is, so you may need to use words like “poop” or “number two.”

Blood in the stool can appear as bright red or black/dark brown. Assessing the color helps determine the cause, which can be something mild to something as severe as colorectal cancer. A focused assessment is important.

If a client has constipation or diarrhea, choose an appropriate action based on the severity. Dietary changes and hydration are often helpful, but in some cases, severe constipation could be related to a bowel obstruction and requires urgent intervention. This may be associated with other symptoms such as abdominal pain and a distended abdomen.

Severe diarrhea can lead to dehydration, which is a serious issue and needs to be treated with rehydration with fluids and electrolytes. Chronic and severe diarrhea could be related to digestive disorders (e.g., lactose intolerance, Crohn’s disease, ulcerative colitis, celiac), viral infection (e.g., norovirus), bacterial infection (e.g., clostridium difficile [C. diff.]), or parasites (e.g., giardia). Contact isolation is required when a client has or is suspected to have infectious diarrhea.

Appetite changes are common symptoms associated with the GI system.

These changes can involve a decrease or increase in appetite (for foods or fluids), and can be physiologically or psychologically related.

Have you had any recent appetite changes (such as decreased or increased appetite)?

If the client’s response is affirmative, additional probes may include:

Quality/quantity: Tell me about the changes. How bad have the changes been?

Timing: When did these changes begin? Are the changes in appetite constant or intermittent? What was going on in your life when these changes began?

Provocative/palliative: Is there anything that makes the appetite changes worse? Is there anything that makes the appetite changes better?

Treatment: Have you treated the appetite changes with anything? Do you take any medications for them?

Understand: Do you know what is causing the appetite changes or what they are related to?

Changes in appetite can be a sensitive issue for some clients. Use a nonjudgmental approach when asking questions, and use words that the client uses when asking additional probes (e.g., when did you begin feeling like not eating?).

Prompt intervention is needed if a newborn is not eating, as adequate nutrition is important to growth and development, and they can also dehydrate easily.

Other GI-related symptoms can include fatigue, unintended weight loss, fever, rectal pain/bleeding/pruritus, and lymph node swelling.

Only ask one question at a time. For example: Have you experienced fatigue (appetite changes, unintended weight loss, fever, rectal pain/bleeding, lymph node swelling)?

If the client’s response is affirmative, use variations of the PQRSTU mnemonic to assess the symptoms further.

Keep in mind that many of these GI-related symptoms can be related to other body systems. Thus, these symptoms require further investigation to determine whether they are related to the GI system. You should assess the severity of rectal bleeding to determine whether prompt intervention is required.

Personal and family history of GI conditions and diseases.

As noted earlier, common issues associated with the GI system include dental cavities, acid reflux, ulcers, cancers, hepatitis, ascites, constipation, and hernias.

Do you have any chronic conditions or diseases associated with your GI system? Do you have a family history of conditions or diseases related to the GI system?

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

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

Timing: When did it occur? 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?

Understanding: Do you have any concerns about how the condition or disease is affecting you?

Some clients may not be familiar with the word gastrointestinal (GI). If so, use words such as the mouth, esophagus, stomach, liver, bowels/intestines.

Some GI-associated diseases have a genetic component, but environmental and cultural factors (family traditions and personal practices) are more likely for many symptoms (e.g., diarrhea, constipation, hepatitis).