11.3 Subjective Assessment

Cardiac pain refers to pain associated with the heart and can be described in many ways such as crushing, pressure, squeezing, tightness, and heaviness in the chest. It is often referred to as chest pain.

It can sometimes be confused with heartburn, but the etiology and treatment of both are different. Therefore, subjective questions are needed to differentiate between these.

Cardiac pain may be felt in the chest, but also in other locations such as the jaw, neck, arms (particularly the left arm), upper back, and abdomen. This type of referred pain occurs because of the sharing of neural pathways.

Do you have pain in your chest? Have you ever experienced pain in your chest?

Additional probes if the response is affirmative:

Region/radiation: Where is the pain located? Does it move around or do you feel it anywhere else?

Quality/quantity: Can you describe what it feels like? How bad is it?

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?

Timing/treatment: When did it begin? What were you doing when it began? Is it constant or intermittent? Have you tried treating it with anything?

Provocative/palliative: What makes it worse? Is it worse when you are breathing deeply? Does it occur after eating? What makes it better?

Understanding: Do you know what is causing the pain?

Apply a cultural humility approach when you consider the meaning of “pain.” Some people may reserve the word to describe severe sensations, so if their symptom is mild they may not refer to it as pain. Others may associate pain with vulnerability and use alternative words to describe it. Therefore, if the response is initially “no,” try rephrasing the question using words such as discomfort, tenderness (e.g., Do you have any sensations in your chest?).

Pain of cardiac origin is a critical finding and requires immediate action. It is considered a first-level priority of care. You should ask a colleague to notify the physician while you keep the client at rest and assess pulse, blood pressure, and oxygen saturations.

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 catch your breath.

Do you have any difficulty breathing? Have you experienced any difficulty breathing?

Additional probes if the response is affirmative:

Quality/quantity: What does the difficulty in breathing feel like? How bad is it?

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 breathing on a scale of 0 to 10, with 0 being no difficulty breathing and 10 being the most difficulty breathing you have had?

Timing/treatment: When did the difficulty in breathing begin? Have you treated it with anything?

Understanding: Do you know what is causing it?

People find the sensation of not being able to catch their breath particularly disturbing because it feels like they are suffocating.

As you are assessing the client, consider raising the head of the bed to make it easier for them to expand their lungs and breathe more easily. However, this decision may be influenced by whether the client’s condition is stable. If they are showing signs of clinical deterioration and their blood pressure is low, lower the head of the bed to increase the amount of blood returning to the heart.

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

Arrhythmias refer to irregular heart rhythms (e.g., atrial fibrillation) or irregular heart rates (e.g., tachycardia, bradycardia).

Some of these arrhythmias can feel like the heart skipping a beat, a palpitation, or a fluttering of the heart.

Do you have any fluttering of your heart or palpitations? Have you ever experienced any fluttering of your heart or palpitations?

Additional probes if the response is affirmative:

Timing: What were you doing when it started? Is it constant or intermittent?

Provocative: Is it worse when you are feeling stressed or anxious?

Other: Do you have any other associated symptoms (dizziness, difficulty breathing, sweating, pain, blurred vision)?

Perform a primary survey (ABCCS) if you are concerned about clinical deterioration.

Assess apical pulse rate and rhythm and blood pressure.

Coughing or wheezing are common symptoms of heart disease, particularly when it affects the lungs. In individuals with heart failure, the blood can back up into the lungs, affecting breathing. Fluid can leak into the lungs causing congestion. Depending on the cause, the client may have expectorate (sputum production from coughing) or hemoptysis (sputum that has blood in it).

Do you have any coughing or wheezing? Have you experienced any persistent coughing or wheezing recently?

Additional probes if the  response is affirmative:

Timing: When did the coughing and/or wheezing begin? How often are you coughing and/or wheezing?

Quantity: How bad is the coughing and/or wheezing?

Other: Do you have any mucus production when coughing? If so, what color is it?

Provocative/palliative: Is there anything that makes the coughing and/or wheezing better or worse?

Until the origin is ruled out, consider it transmissible. You and the client should both wear a mask. Additionally, you should consider putting on a face shield.

Follow a process similar to one you would use for a client with dyspnea.

Peripheral edema is swelling that occurs from excess fluid in the tissues. When it is cardiac-related, it is usually caused by the heart not pumping adequately and blood backing up causing swelling. It is most easily noticed in peripheral locations such as the feet and legs because gravity pulls the fluid downward into these dependent position, but it may also be observed in the sacrum, abdomen, hands, and arms.

Have you noticed any swelling or puffiness in your feet or ankles (or any other areas)? Have you noticed that your shoes fit tight on your feet?

Additional probes if the response is affirmative:

Region: Where is the swelling?

Timing: When did the swelling begin? Is the swelling worse at a particular time of day?

Provocative/palliative: Does anything make the swelling worse or better?

Other: Have you noticed any associated color changes to the skin? Do you have difficulty walking? Have you noticed any skin ulcers on your feet or legs? Do you have increased urination at night? Have you noticed a recent and rapid weight gain in the last week?

Assess whether the edema is acute or chronic and unilateral or bilateral. This will help you focus your questioning. If it is acute and unilateral, it may be a localized issue such as deep vein thrombosis (DVT) or an injury. If it is chronic and bilateral, it is more likely to be a systematic issue such as heart failure.

Nocturia and edema are often related symptoms. At night when a person lies down, gravity no longer retains the fluid in the peripheries. As a result, the fluid returns to the veins and some is filtered by the kidneys, producing an increase in urine. Since blood is returning to the veins and being pumped to the heart, the edema can also lessen.

Edema and rapid weight gain are also sometimes related. Rapid weight gain can be suggestive of increased fluid retention (leading to edema) and is often associated with heart failure. A 2–3 lb (.9 to 1.3 kg) weight increase in 24 hours is a cue that requires immediate action.

Complete a focused assessment on respiratory, cardiovascular, peripheral vascular, and skin.

Other cardiovascular related symptoms can include fatigue, lightheadedness, diaphoresis, nausea, decreased appetite, and color changes such as cyanosis.

Always ask one question at a time.

Have you experienced fatigue (lightheadedness, sweating, nausea, decreased appetite, skin color changes)?

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-cardiac issues. Therefore, it is important that these symptoms be explored specifically if there were affirmative responses to the other common cardiac-related symptoms.

Personal and family history of cardiovascular issues. These may include risk factors, conditions, and diseases.

Do you or your family members have high blood pressure or high cholesterol? Have you or your family members ever had a heart attack? Do you or your family members have heart failure? Do you or your family members have any issues associated with the valves of the heart? Are you aware of any other personal or family history of cardiac issues that I may have not mentioned?

Additional probes if the  response is affirmative include further exploration using the PQRSTU mnemonic. Also ask about age of diagnosis, and if relevant, age of death of family members.

The biological and non-biological nature of family may be important to explicate when asking questions, considering that the risk factors may be influenced by genetics and/or culture. Although there is a genetic role to some cardiac conditions and diseases, it is also important to consider culture, as family traditions and practices have a large role to play in health (e.g., eating habits, activity/exercise, smoking). With some clients who have high cholesterol, there can be a genetic component leading to familial hypercholesterolemia. This is an inherited condition (the gene is present at birth) that leads to hypercholesterolemia (high levels of cholesterol in the blood). Thus, the age that a person or their family member develops hypercholesterolemia as well as hypertension is important to assess.

It is important to inquire about high blood pressure in current or past pregnancies. High blood pressure can be associated with complications for the women and the fetus. Thus, it is measured at each prenatal care visit.