9.4 Subjective Assessment

Dyspnea 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.

The feeling of not being able to catch one’s breath is particularly upsetting because it feels like suffocation.

When a client is having difficulty breathing, they often also have rapid breathing: tachypnea.

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 vital capacity, and increased residual volume.

Do you currently have any difficulty breathing or shortness of breath? 

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

Additional probes if the client’s responses are affirmative:

Quality: What does your difficulty in breathing feel like?

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?

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?

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?

Understanding: Do you know what is causing the difficulty in breathing?

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’s 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.

Use a primary survey (ABCCS) approach to determine cues that may indicate clinical deterioration. Assess the client’s respiration rate, work of breathing, and oxygen saturation; and then pulse, blood pressure, and temperature; followed by auscultation of lungs.

Coughing, also known as “tussis,” is a common respiratory symptom. It is usually an involuntary reflex involving expulsion of air from lungs or an attempt to clear one’s throat/breathing passages from foreign bodies, irritants, fluids, and mucus.

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.

Do you currently have a cough or have you recently had a cough?

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

You will probably need to probe further. Additional questions might include:

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 color is it?

Timing/treatment: When did the coughing begin? Is it constant or intermittent? Have you treated it with anything?

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?

Region: Do you feel the cough is worse in a particular area? (e.g., throat, lungs)

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?

Understanding: Do you know what is causing the coughing?

Until the origin is ruled out, consider it transmissible. Wear eye protection, and you and the client should both wear face masks.

You should consider raising the head of the bed. A client who is coughing with expectorate might be more comfortable sitting upright.

Assess the client’s respiration rate, work of breathing, oxygen saturation, and then pulse, blood pressure, and temperature, followed by auscultation of lungs.

Chest and nasal congestion is accumulation of mucus in the chest/lungs and/or in the nasal cavity/nose.

This congestion may be associated with coughing, runny nose, and sneezing.

Do you have any chest or nasal congestion?

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

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

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

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

Region: Where do you feel the congestion?

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

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

Assess the client’s respiration rate, work of breathing, and oxygen saturation; and then pulse, blood pressure, and temperature; followed by auscultation of lungs.

Sinus pain/pressure is a sensation felt in the sinuses. It is commonly associated with inflammation, infection, and/or blockage of the sinuses.

Do you have any pain or pressure in your sinuses?

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

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

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

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

Region: Where do you feel the pressure/pain?

Treatment: Have you treated it with anything?

Do you take any medications for it?

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

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.

The location of the sinus pain is important to assess to potentially help determine the cause and the sinuses affected.

Wheezing is a whistling sound or noisy breathing associated with inspiration and/or expiration. It is commonly associated with narrowing of the airways, inflammation, and bronchospasm.

Do you hear any wheezing when you breathe?

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

You can probe further with questions related to the PQRSTU mnemonic such as:

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)

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.

If a client is currently wheezing, it is essential to rule out anaphylaxis, 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 pruritus, rash/hives, difficulty swallowing, swelling of face or lips, and nausea.

Administration of epinephrine is a priority if anaphylaxis is suspected.

Chest pain associated with the respiratory system can be described in many ways: a sensation in the chest, discomfort, tenderness, tightness, and sharp pain.

Depending on the etiology, the pain can worsen when breathing and coughing.

Do you currently or have you recently had any chest pain or sensations in your chest?

If the client’s response is affirmative, first ask: Do you have the pain now?

Additional probes may include:

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?

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

Region: Where do you feel the pain/sensation?

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

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

It is important to address any current pain, particularly if it could be of cardiac origin.

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.

Assess the client’s respiration rate, work of breathing, oxygen saturation, and then pulse, blood pressure, and temperature, followed by auscultation of lungs.

Other respiratory symptoms can include fatigue, perspiration, confusion, light-headedness, sneezing, sore throat, headache/body aches, fever/chills, color changes in skin/lips/nails (such as cyanosis), lymph node swelling, and decreased appetite.

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

Have you experienced fatigue? (Or perspiration, confusion, lightheadedness, sneezing, sore throat, headache/body aches, fever/chills, color changes of your skin/lips/nails such as cyanosis, lymph node swelling, decreased appetite?)

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

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.

Personal and family history of respiratory conditions and diseases.

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 coronaviruses.

Do you have any chronic respiratory conditions or diseases? Do you have a family history of respiratory conditions or diseases? (e.g., asthma, allergies, emphysema)

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, 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?

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 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.