7.3 Subjective Assessment
Subjective assessment of the MSK system involves asking questions about the health of the client and symptoms that may occur because of pathologies that affect the muscles, bones, and joints. A full exploration of these pathologies is beyond the scope of this chapter, but common problems associated with the MSK system include back pain, repetitive strain injury (RSI) such as carpal tunnel syndrome or tendinitis, osteoarthritis, rheumatoid arthritis, sprains, and bone fractures.
Common symptoms that can be related to the MSK system include pain, headache, stiffness, muscle tightness, numbness, weakness, muscle twitches, fatigue, mobility, redness, swelling, local temperature change, deformities, and psychological distress. See Table 7.1 for guidance on subjective health assessment. Many of the questions in this table align with the PQRSTU mnemonic; for a reminder, check out this resource: PQRSTU. Probing of these symptoms should occur in the order of relevance, as opposed to being sequentially aligned with the PQRSTU mnemonic.
You should also ask about any medications (prescribed, over the counter, and herbal and natural products) the client is taking: the name, dose, frequency, reason it was prescribed or rationale for taking over-the-counter medications, how long they have been taking it, and the effectiveness.
The subjective assessment is performed prior to the objective assessment so that it can inform the objective assessment. 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 “Health Promotion Considerations and Interventions” is included later in this chapter after the discussion of objective assessment.
Knowledge Bites: Pathophysiology
Many MSK-related pathophysiology disorders are related to physical work (e.g., working at a computer, lifting boxes) and workplace injuries, which can be prevented or decreased by implementing health promotion strategies. MSK injuries can occur in the muscles, nerves, tendons, joints, cartilage, and bones. Certain work environments can increase the risk of or worsen an MSK injury. For example, work that involves routine lifting, performing repetitive tasks, or work that challenges the ergonomics of your body (e.g., working at a computer for lengthy periods of time). Common workplace musculoskeletal disorders include sprains, back pain, tendonitis, and carpal tunnel syndrome. Proper body alignment and ergonomics can help decrease the risk of a MSK workplace injury.
| Symptoms | Questions | Clinical tips |
| Pain associated with the MSK system can be described in many ways such as aching, sharp, cramping, stiffness, or burning sensation. Myalgia is a term that refers to muscle aches and pains.
Clients may tell you about pain in their muscles, joints and bone. Sometimes they might not be able to specify, but instead just show the location. Thus, your assessment is important to figuring out the issue. |
You might start by asking: Do you currently or have you recently had any pain or other sensations in your joints, muscles, or bones?
If the client’s response is affirmative, ask: Do you have the pain now? Additional probes may include: Region: Where do you feel the pain/sensation? Radiation: Does the pain radiate to another part of your body? Quality/quantity: Tell me about it. What does it feel like? How bad is it? Severity: Can you rate your pain on a scale of 0 to 10 with 0 being no pain and 10 being the most pain you have ever had? Timing: When did it begin? What were you doing when it began? Is it constant or intermittent? Do you wake up with the pain and if so, how long does it last? Provocative/palliative: Is there anything that makes it worse? (If you suspect a fracture, it may be appropriate to ask if movement increases the pain because fractures can cause sharp, intense pain with movement). Is there anything that makes it better? Treatment: Have you treated it with anything? Do you take any medications for it? Does it work? Have you sought treatment regarding this pain? If the pain is in the lower extremities, does walking relieve or aggravate it? Understanding: Do you know what is causing it or what it is related to? Did you have a recent injury? Other questions: How does the pain affect your life? Does it affect your activities of daily living? What type of work do you do? Does it involve physical activity or heavy lifting? Does it involve sitting/standing for long periods of time? |
If the client has had an injury or a fall, you may suspect a fracture if they describe a sharp and intense pain on movement or when they attempt to bear weight. If you suspect a fracture, assess for potential deformities, swelling, and decreased circulation distal to the location. Immediate help may be required to decrease the risk of further injury to the MSK, peripheral vascular, and nervous systems, as well as respiratory system (e.g., a fractured rib).
When caring for clients with impaired cognition or with clients who are preverbal or nonverbal, refer to the pain assessment chapter, particularly pain tools related to children, cognitive impairment, and critical care. When possible, clients should monitor their pain level and treatment strategies with chronic pain. You might ask them to document their pain in a journal and discuss further strategies for pain management. Types of pain management strategies for some MSK conditions may include non-opioid medications, e.g., acetaminophen or ibuprofen. Non-medicinal pain strategies could include deep breathing exercises, massage, physiotherapy, stretching, ice and heat, and some rest (but you should tell the client it is important to maintain light activity). |
| 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.
You should inquire about the presence of severe and frequent headaches. Headaches can be related to the MSK (e.g., tension or cervicogenic headaches) or neurological system (e.g., migraine). Assessment will help you start thinking about which system could be causing the headache. A headache can be the primary cause (e.g., migraine, tension headache) or secondary cause (e.g., cervicogenic or sinus headaches). For example, migraines are primarily related to the neurological system, but head/neck pain and stiffness can occur due to tension that can affect the MSK system; this would be considered a secondary cause. |
Do you currently have a headache? Have you recently experienced any headaches that you are concerned about? Do you have frequent, severe, and/or reoccurring headaches that disrupt your day-to-day functioning?
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 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? 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 of your family experience similar headaches? Other: How does it affect your daily life? |
Almost everyone has had a headache. Common causes include stress, dehydration, changes in sleep, poor posture/body alignment, and certain foods (e.g., nitrates).
Frequent and severe headaches are more concerning. It is important to determine if the headache is primary (e.g., migraine, tension) or secondary and related to another medical condition (e.g., head injury, trauma, tumor, stroke). A sudden onset of a severe headache may require immediate intervention. You should call for emergency help if it is accompanied by confusion, trouble seeing, speaking, or walking, fainting, or numbness/weakness. This kind of headache could be related to a stroke, brain aneurysm, or other serious medical condition. |
| Joint stiffness refers to when joint movement is limited or difficult (medical term is ankylosis). The joint may feel achy or sore.
Joint stiffness can be caused by degeneration of cartilage and/or decreased synovial fluid being produced with age. It can also be caused by other MSK conditions such as arthritis, gout, or bursitis. |
Do you currently have any stiffness in your joints? Have you had any recent stiffness in your joints?
Additional probes if the client’s responses are affirmative may include: Quality/quantity: What does it feel like? How bad is it? Region: Which joints feel stiff? Timing: When did it begin? Is there a time of day when the stiffness is worst? Is it constant or intermittent? If intermittent, how long does it last for? Provocative/palliative: Is there anything that makes it better (e.g., position)? Is there anything that makes it worse (e.g., exercise or sitting for long periods of time)? Is it aggravated or associated with any specific movements? Treatment: Have you treated it with anything (e.g., ice, heat, exercise)? Do you take any medications or supplements for it? Do you use any mobility aids? Understanding: Do you know what causes your joint stiffness? Do you have any related symptoms (e.g., pain, swollen glands or lymph nodes, increased saliva production)? Other: How does it affect your ability to move around? How does it affect your sleep? |
Joint stiffness is a common MSK concern. Understanding the pathophysiology of the cause of the stiffness will help you determine effective interventions.
You should assess the location of the joint stiffness to help determine the cause and whether and how it is affecting the client’s activities of daily living. Preventive strategies that can ease joint stiffness include gentle range of motion movements, exercise (e.g., walking), hot and cold compresses, good body alignment/posture, managing weight, and balancing rest and activity. |
| Muscle spasms are involuntary muscle contractions.
The cause of muscle spasms is often unknown, but they can be related to inactivity, fatigue, stress, lack of stretching, dehydration, overuse of the muscle, or pain. Muscle spasms can feel like a twitch or cramping and can create pain. |
Do you experience muscle spasms?
If the client’s response is affirmative, additional probes might include: Quality/quantity: Tell me about the muscle spasm. What does it feel like? How bad is it? Region: Which muscle(s) has the spasm? Timing: How often do you have them? When did it begin? When do you feel the muscle spasm (e.g., at night, after exercise)? Is it constant or intermittent? Provocative/palliative: Is there anything that makes it better? Is there anything that makes it worse? Is it aggravated or associated with any other symptoms? Treatment: Have you treated it with anything (e.g., stretching, hot or cold compresses)? Do you take any medications or supplements for it? Understanding: Do you know what caused the muscle spasm or what it is related to? |
Assess the cause of the muscle spasm and associated signs and symptoms. If it is related to a neurological system concern, symptoms will vary (e.g., numbness, paralysis, tremor) and other interventions will be required.
Adequate water intake, especially during exercise or warm weather, will assist with dehydration-related muscle spasms. Some clients will describe intense muscle spasms in the night, particularly in the calf muscle. Stretching and massaging the spasm can relieve the symptoms. Stretching before and after activities, as well as after being stationary for long periods, will help decrease the risk of muscle spasms. |
| Mobility, lack of balance, and weakness.
A person’s mobility can be affected and limited by their joints, muscles, or bones, as can lack of balance and weakness. |
Tell me about your mobility. Tell me about your daily activities and exercise.
Do you have any limitations when walking, standing, sitting, or any other body movements? Do you have mobility limitations? For example, do you have any concerns with your balance or any weakness while moving? Do you use any mobility aids (e.g., walker, cane, crutch, bar handles, wheelchair, prosthetics)? If the client’s response is affirmative, additional probes might include: Quality/quantity: Tell me about your mobility concerns. What does it feel like? How bad is it? Region/radiation: Which part of your body experiences limitations or weakness related to your mobility/movement? Does the limitation/weakness remain in the one location or does it move to another location (e.g., hip to knee)? Does this happen when you walk for longer periods of time? Timing: When do you feel a lack of balance or weakness when you are mobile? When did the mobility concerns begin? How long have you been experiencing the limitation or weakness? Is it constant or intermittent? Provocative/palliative: Is there anything that makes it better? Is there anything that makes it worse? Does a certain movement or activity aggravate it or make it feel better? Is it associated with any other symptoms (e.g., pain or numbness)? Treatment: Have you treated it with anything (e.g., stretching, hot or cold compresses, mobility aids)? Do you take any medications or supplements for it (e.g., ibuprofen, fish oil)? Do you regularly use any mobility aids? Understanding: Do you know what caused the mobility issue or what it is related to? How does it affect your daily life? |
Mobility will depend on the client’s developmental age, current health, and morbidity status. It can also be affected by certain medications that can affect balance or cause fatigue.
Help the client take precautions against falling. A careful assessment is needed for any client at risk of falling. Various assessment tools are available to systematically assess risk factors related to falls, which include 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 recommendations, as well as all institutional policies to prevent falls. If the client has mobility limitations, assess how this affects their overall daily life (e.g., physically, psychosocially, financially). |
| Redness, swelling, temperature changes, and deformities may be related to the joints, muscles, or bones. | Always ask one question at a time. Questions might include:
Have you experienced any redness (or swelling or temperature changes or deformities) in any joints (or muscles or bones)? 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 MSK system or another body system. You should assess each symptom individually to determine the systematic cause. |
| Injury and trauma can cause a range of musculoskeletal symptoms and/or exacerbate existing issues. It is important to explore the mechanism of injury.
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Have you had any recent injuries/trauma?
If the client’s response is affirmative, additional probes might include: Quality/quantity: Tell me about the injury/trauma. What does it feel like? How bad is it? Region/radiation: Which part of your body experienced the injury/trauma? Have the effects of the injury/trauma remained in one location or is another location affected? Timing: When did the injury/trauma occur? How long have you been experiencing it? Provocative/palliative: Is there anything that makes it better? Is there anything that makes it worse? Treatment: Have you treated it with anything? |
Understanding the mechanism of injury and how the injury occurred will inform your objective assessment and interventions. |
| Other MSK symptoms can include fatigue, numbness, dizziness, or flu-like symptoms. | Always ask one question at a time. Questions might include:
Have you experienced any body fatigue? (or numbness or dizziness or flu-like symptoms?) 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-MSK issues. To determine whether they are MSK related, you will need to explore these symptoms along with any other associated symptoms. |
| Personal and family history of MSK conditions and diseases.
Some of the common issues associated with the MSK system, including back pain, repetitive strain injury (RSI) such as carpal tunnel syndrome or tendinitis, osteoarthritis (OA), rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), gout, and fibromyalgia, can have a familial connection. |
Do you have any chronic conditions or diseases that affect your muscles, bones, and joints? Do you have a familial history of conditions or diseases that affect the muscles, bones, and joints (e.g., arthritis, lupus, gout, and fibromyalgia)?
If the client’s response is affirmative, begin with an open-ended probe: Tell me about the condition/disorder/disease. If the client has a personal history, probing questions might include: Timing: When did you begin experiencing symptoms related to this condition? When were you diagnosed? Are the symptoms constant or intermittent? Quality/quantity: How does it affect you? What symptoms do you have? How bad are the symptoms? Treatment: How is it treated? Have you had any surgeries? 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 and/or environmental factors.
Some musculoskeletal disorders are related to genetics (e.g., (e.g., achondroplasia, Duchenne muscular dystrophy, osteogenesis imperfecta), but it is more common that a combination of environment and cultural factors play a larger role (e.g., osteoarthritis, degenerative disc disease). |
Priorities of Care
All abnormal findings require a focused assessment on the MSK system and possibly other systems. However, certain MSK symptoms are cues that require immediate action.
A sudden, very severe headache that is worse than the client has ever experienced before requires urgent assessment. It could be a sign of a life-threatening condition such as an aneurysm or a ruptured aneurysm. Other associated symptoms include reduced consciousness, disorientation, eye pain, light sensitivity, and blurred vision. If your client has this sort of headache, you should immediately report it to the physician or nurse practitioner, monitor the client’s vital signs, and conduct focused assessments (on the MSK, neurological system, and the eye).
Additionally, if you suspect a potential fracture, you should perform a focused assessment. A bone fracture is highly probable if the client experiences a sharp and intense pain upon movement, particularly when they have experienced some sort of trauma (e.g., a fall). Take immediate action to decrease the risk of further internal trauma to the peripheral vascular systems (e.g., circulation), nervous system, or other organ damage (e.g., punctured lung or perforated bowels). For example, with a clavicle fracture, the sharp edge of a broken bone could damage the underlying vessels (e.g., internal jugular vein), nerves (e.g., brachial plexus) or puncture the apex region of the lung (e.g., pneumothorax). When a fracture is suspected:
- Assess pain level.
- Immobilize the area and do not attempt to realign the bones.
- Monitor vital signs frequently (particularly respiration, pulse, and blood pressure) and perform a primary survey (ABCCS).
- Assess circulation and sensation distal to the injury including skin temperature, sensations, and pulses: cool temperature, numbness/tingling, and decreased or absent pulses.
- Report findings to the physician or nurse practitioner.
Contextualizing Inclusivity
Recognize that some clients may have extensive MSK histories, particularly older clients, and ensure you allow sufficient time for assessment. Children may experience what is often called growing pains; this type of pain is an achy muscle pain typically in the legs.
Also, you may have certain values surrounding activity and exercise and/or concerns about your own body image. Try to reflect on your own unconscious biases: this will help you support each client’s agency and their own mobility goals while connecting them with supportive resources within their communities.
Some clients with MSK limitations may feel hesitant to participate in sports or activities. For example, they may feel uncomfortable because of self-concept or body image issues associated with their limitations, mobility aids, or physical deformities. It is important that you create an inclusive environment, and be aware of the client’s potential discomfort. For example, you may begin the assessment with a nonjudgmental question such as: “What type of activities (or sports) do you enjoy?” This can open a discussion about participating in sports or group activities, which can provide many benefits to the client’s concept of self. Interacting and socializing with others in a shared activity can create a sense of inclusion, as well as have positive health benefits, both physical and emotional.
Listen to Justin Gallegos’ story about being part of his high school cross-country and track team: No Such Thing as a Disability: The story of a runner with cerebral palsy.
Activity: Check Your Understanding
A 67-year-old client, pronouns she/her, came to the health clinic concerned about being constipated for the last 2 ½ weeks and has been experiencing cramping and pain in her left lower quadrant (LLQ) for the past 4 days. She reported feeling like she has to have a bowel movement (BM) but nothing comes out and she is worried she might have hemorrhoids. Today she began to feel nauseous. The client explained she was diagnosed with multiple sclerosis (MS) 5 years ago and that when she is stressed, her MS flares up and she gets constipated. Her daily life routine has been altered recently because she has been taking care of a friend who had heart surgery. Her vital signs are: blood pressure (BP) 138/88 mm Hg, pulse (P) 92 beats per minute, respirations (RR) 18 breaths per minute, oxygen saturation (O2 sats) 98% and oral temperature (T) 37.9 degrees Celsius.
The original version of this chapter contained H5P content. You may want to remove or replace this element.
The nurse learns the client experiences these symptoms a couple of times per year when her MS flares-up. When not having a flare-up, the client normally has a bowel movement 5–6 times per week. The client reported that her diet and exercise has been interrupted due to helping a friend. She said that she usually eats a healthy diet, walks 30–60 minutes 5 times per week, and does yoga 3 times per week. During the last 2 weeks, she has not exercised and has been ordering take-out. Other symptoms include straining when having a bowel movement, passing small hard stool, and a bit of bleeding during the last bowel movement. The client’s constipation usually resolves after a week, but she believes it has lasted longer due to the added stress in her life.
Coming soon!
Health promotion and disease prevention are important components of any assessment, including a GI system assessment. Consider all available subjective and objective data when determining appropriate interventions. As part of subjective data collection, ask the client about risk factors, social determinants, and other considerations.
The inquiry part is integrated throughout the assessment. Many of the probing questions may be asked when doing the subjective assessment. However, some of the questions will be formulated based on your critical reflection of data collected during the subjective and objective assessment. It is this data that will inform your clinical judgment and the health promotion needed for a specific client.
Hand Hygiene
Hand hygiene is necessary to maintain a healthy GI system and prevent unhealthy microorganisms from entering the body. Hand hygiene can decrease the risk of various mouth and other GI-related viruses, such as herpes simplex virus type 1 (e.g., cold sores, fever blisters) and viral gastroenteritis (e.g., stomach flu), parasites on the surfaces of soil, food, and water (e.g., giardia), and bacteria found in the mouth that cause decay (e.g., Streptococcus mutans) or in contaminated food that can cause diarrhea and stomach cramps/pain (e.g., Salmonella).
Probing questions related to hand hygiene include:
- Tell me about when you wash your hands?
- How often do you wash your hands?
- What is involved in washing your hands? (Further probes might include: What are the steps involved? How long do you do it for?)
You may need to educate the client about effective hand hygiene practices such as when to perform it and how to do it. This education should be dependent on the client’s age. For example, you could teach a child to wash their hands along with their favorite song or a fun educational video; with older adults, you could introduce various assistive devices (e.g., nail brush) for clients with limited fine dexterity. Teach clients to perform hand hygiene frequently in healthcare and in work settings, as well as when they arrive at and leave a building, come home, before meal preparation, before and after meals, and before and after using the washroom.
Hand hygiene generally refers to either hand washing with soap and water or hand sanitizing with an alcohol-based hand rub. The mechanical actions of rubbing and creating friction helps to break down and remove various microorganisms from hands, preventing them from entering the mouth and the rest of the GI tract. Clients may require education about specific techniques.
Hand washing technique:
- Rinse hands with warm water, lather with soap for 20 seconds.
- Rinse hands with water.
- Dry hands with a paper towel.
- Turn off the tap with your elbow or the paper towel.
NOTE: Consider how to make it fun with children, for example by singing a song that lasts 20 seconds.
Hand sanitizing technique with alcohol-based hand rub:
- Ensure hands have no soil on them and are visibly clean.
- If there is visible soil, perform hand washing instead.
- Dispense a sufficient amount of gel in hand.
- Rub hands together so that all areas of the hands are covered.
- Rub hands together for about 15 seconds until they are dry.
- If hands dry before 15 seconds, use more hand gel.
Mouth Care and Dental Care
Mouth and dental care is an important part of maintaining the health of the oral cavity of the GI system, particularly the teeth and gums.
Probing questions related to mouth care and dental care include:
- Tell me about any personal mouth and dental care you perform. Probing questions could include:
- How often do you brush your teeth?
- How often do you floss?
- Can you tell me about your brushing technique (e.g., brushing away from gums, type of toothbrush)?
- When was the last time you saw a dentist for a check-up or a hygienist for a dental cleaning? How often do you typically have your teeth cleaned?
- Do you have any concerns about your mouth and dental care?
Begin by addressing any of the client’s concerns about their mouth and dental care. Remember to consider relational and structural approaches to health promotion. For example, children learn how to brush their teeth and maintain a schedule based on support from their parent/caregiver. Thus, it is important that you assess social and familial support related to dental care. Based on your assessment and the client’s needs, you may need to provide health promotion education about mouth and dental care.
The Canadian Dental Association (2021) recommends brushing teeth at least twice a day, flossing once a day, and having a cleaning about every six months. However, there are many inequities associated with dental care, for example geographical access to a dentist when living in rural, remote, and Northern communities. Some communities lack access to clean water, and some water systems are not fluoridated. Almost 30% of the water systems in Ontario are not fluoridated, and this has a significant effect on dental decay. The lack of fluoridated water systems has been identified as a problem for many Indigenous communities (Public Health Agency of Canada, 2017).
Another consideration is the financial costs associated with dental cleanings and dentist appointments. These are not always covered under provincial and territorial health insurance plans in Canada. Ask the client if they are covered under a private insurance plan related to their work or under a family member’s plan or through their post-secondary educational institution. Ontario has a dental care program for children under the age of 17 from low-income families (Ontario dental care - children). Also check out the new Canada Dental Care Plan that was developed to help ease financial barriers in accessing oral health care for eligible Canadian residents. Also, check out information about flossing). Some dental schools also provide dental care at minimal cost.
Diet
Diet affects the functioning of the GI system. A healthy diet helps maintain the health of the GI system, fuels the body to function, and maintains an ideal body mass index; a diet high in fibre with adequate hydration helps keep the intestines moving and bowel movements regular. In contrast, an unhealthy diet can lead to malnutrition, obesity, dental decay, altered bowel patterns such as constipation and diarrhea, and can affect other body systems and lead to various health problems such as diabetes, some cancers, cirrhosis, and heart disease.
Malnutrition is when when the body does not have sufficient vitamins, minerals and other nutrients to maintain a healthy GI system as well as healthy tissues and organs. Malnutrition can be related to undernutrition or overnutrition.
Check out this video about how the food you eat affects your gut. It was created by Dr. Shilpa Ravella, a gastroenterologist.
Probing questions related to diet could include:
- Tell me about your usual diet?
- What have you eaten in the last 24 hours? Is that your usual diet?
- How often do you eat X or drink X? (X refers to a specific food or fluid and getting an understanding of the frequency of consuming certain foods can provide information related to malnutrition disorders)
- Do you have any food allergies or intolerances? (Further probes could include: What type of allergies? What is the reaction? (e.g., anaphylaxis, rash) When did the allergy start? How do you treat it?)
- Do you have enough money to buy healthy food?
- Tell me about your cultural practices related to diet?
In addition to assessing what they ate in the last 24 hours, it can sometimes be helpful to elicit a more comprehensive understanding of their diet particularly when there are health problems associated with the GI system (e.g., chronic diarrhea or constipation). In this case, you may ask the client to keep a food diary for a set period of time such as a week. The client can identify anything they consume with the date/time and also keep track of any symptoms. In clients who are hospitalized, observation is often employed to monitor the client's food and fluid intake and help tailor diets to the client's likes and nutritional needs.
You could assess the client’s familiarity with Health Canada's Food Guide (Government of Canada, 2021) and discuss how they might draw upon it to guide their food choices. Remember that the food guide still includes Eurocentric elements, so you should collaborate with the client about its relevance in the context of their cultural food practices. A food guide snap shot available in multiple languages and many resources have been developed for Indigenous populations.
Informed by Canada’s Food Guide, some key elements to discuss with a client when promoting a healthy diet include:
- Eating patterns and cultural practices.
- Making water the drink of choice.
- Making time to enjoy the meal, eating mindfully, allowing the food to digest.
- How to incorporate fibre, probiotics, fermented foods (e.g., kimchi), polyphenols (e.g., almonds), and a variety of food options to promote gut healthy nutrients.
Assess each client’s lifestyle to understand how it affects their diet and how you can help them adapt to include healthier food choices when possible. Use the relational health promotion approach to learn what food and diet means to the client and how their environment and the people within it can influence their choices. For example, young adults attending college or university may have limited access to healthy food choices due to a prevalence of fast food vendors at their institution. In this sort of situation, when a client lacks access to healthy food resources, nurses can source out and advocate for access to food resources within the client’s community (e.g., food banks, breakfast programs), help the client find accessible food services (e.g., student nutrition program), or help the client find resources for grocery delivery. Nurses need to advocate to ensure the particular needs of each client are being met, using the available socioeconomic and environmental resources. By working in partnership with each client, you can create effective interventions that support the client in achieving a healthy diet.
Smoking, Alcohol, and Cannabis
Smoking or chewing tobacco has negative effects due to the risk of cancer in the mouth, tongue, esophageal, stomach, pancreas, and liver. Alcohol and cannabis can have positive and negative effects on the GI system.
For example, red wine contains polyphenols from the skins of the red grapes. Polyphenols are plant-based compounds that are healthy for intestinal bacteria; evidence suggests that polyphenols have a probiotic effect on intestinal bacteria (Moorthy et al., 2020). However, this is not a good reason to start drinking wine, because many plant-based foods such as fruits contain polyphenols. Moreover, alcohol can have negative effects on your GI tract: it can cause diarrhea in some due to increased acid production in the intestines, and constipation in others due to its diuretic effect. Some people are also intolerant to the additives in alcohol (e.g., gluten in beer). The liver is the main organ that processes alcohol, and heavy drinking over a long period can damage the liver and lead to cirrhosis. Additionally, because the liver processes many medications, a damaged liver can affect how medications are absorbed and their effects. The most recent Canadian guidelines now suggest that there are health risks associated with any level of alcohol consumption, although negligible with two drinks or less weekly (Paradis et al., 2022). From a GI perspective, alcohol is a carcinogen that is linked to colon cancer as well as rectum, mouth, liver, and esophageal cancer (Paradis et al., 2022). Overall, the key is to consume limited amounts of alcohol.
The Canadian Society of Intestinal Research has reported that cannabis can be used effectively to treat loss of appetite and nausea and vomiting related to GI conditions such as irritable bowel diseases (IBD) and multiple sclerosis (MS) (medical Cannabis). However, negative GI-related effects of consuming cannabis have also been reported: some individuals are allergic, and long-term use can cause cannabinoid hyperemesis syndrome, which causes nausea, vomiting, and abdominal pain. Overall, clients should discuss cannabis use with their primary healthcare provider prior to consuming.
Probing questions related to alcohol, cannabis, and smoking could include:
- Tell me about how much alcohol you consume in a day? If the client does not consume alcohol daily, you can assess consumption based on weekly, monthly, or none. If the client’s answer is affirmative, ask probing questions such as: How much (e.g., ounces a day)? What type of alcohol (e.g., red wine, beer)? For how long? Can you tell me the reasons?
- Do you smoke or ingest cannabis? If affirmative, ask similar probing questions as above. Also ask if it is medically prescribed or recreational.
- Do you smoke cigarettes or use any tobacco-related products? If affirmative, ask similar probing questions as above examples. Also ask if the client inhales or chews tobacco.
- If you do not currently consume alcohol/cannabis/smoking, have you ever? If affirmative, you can ask similar probing questions as above, including the reason that the client quit.
- Have you had an allergic reaction to alcohol or cannabis? If affirmative, ask probing questions such as: What is the reaction (e.g., anaphylaxis, irritable bowel)? When did it start? How do you treat it?
Health promotion education should focus on each client’s lifestyle and reasons for consuming alcohol, cannabis, or tobacco. Interventions related to using safely or quitting the consumption should be tailored to each client and could include counselling, cognitive-behavioural therapy, and support groups. You should also consider the relational promotion approach: for example, a client’s consumption can be influenced by their surrounding environment (e.g., family, friends, workplace).
If the client is interested in using medical cannabis, your role as a nurse is to understand their interest and help them find appropriate resources specific to their needs. You can also advocate for educational resources about medical cannabis if a client’s healthcare setting or community lacks resources or support.
Activity
Activity and exercise promote peristalsis of the intestines ensuring that content moves along the digestive tract and helps to maintain a healthy body mass index. It is important for individuals to eat healthy and drink an adequate amount of fluids (primarily water) based on their age, genetics, and activity level. Guidelines vary, but it is suggested that individuals participate in about 30 to 60 minutes of aerobic activity five to seven times per week.
Check out this video about improving digestion with movement. It was created by Dr. Jaclyn Tolentino, a family medicine physician.
Probing questions related to activity could include:
- Tell me about your activity or exercise routine?
- What is your exercise routine? What type of exercise? How long do you do this type of exercise for? How many days of the week do you participate in exercise? If the client engages in sports, ask about protective equipment.
- Do you have any mobility limitations?
- Do you have any concerns about your level of activity or exercise?
- Do you have any goals you would like to achieve related to your activity or exercise level?
Assess and collaborate with each client to create an activity/exercise care plan that is based on their goals and needs. The care plan should be realistic and attainable for the client according to their physical capabilities, environment, and availability. You can also assess the client’s access to support systems for additional support, such as community walking groups, fitness apps, and local gym memberships. The participACTION website is a helpful website
Remember to assess the client’s broader community structures. For example, does the client’s community have accessible, safe sidewalks or streetlights. This kind of structural approach to health promotion can help address potential inequities. Access to services can vary and can be a barrier to the client’s exercise/activity goals. Other barriers might include finances (e.g., gym memberships, sports registration fees) or geographical location (e.g., different resources available in urban, rural or remote regions). As a nurse, you will need to tailor activity programming to each client. You can also advocate for structures to address inequities.
References
Canadian Dental Association (2021). Flossing and brushing. http://www.cda-adc.ca/en/oral_health/cfyt/dental_care_seniors/flossing_brushing.asp
Paradis, C., Butt, P., Shield, K., Poole, N., Wells, S., Naimi, T., Sherk, A., & the Low-Risk Alcohol Drinking Guidelines Scientific Expert Panels. (2022). Update of Canada’s Low-Risk Alcohol Drinking Guidelines: Final Report for Public Consultation. Ottawa, Ont.: Canadian Centre on Substance Use and Addiction.
Public Health Agency of Canada (2017). The state of community water fluoridation across Canada. https://www.canada.ca/en/services/health/publications/healthy-living/community-water-fluoridation-across-canada-2017.html
- Common symptoms to assess related to the GI system include pain, nausea and vomiting, appetite changes, food intolerances and allergies, changes to bowel patterns including diarrhea and constipation, bloating, and flatulence.
- An objective assessment of the GI system is first performed with the client sitting upright to assess the oral cavity and then lying supine to assess the abdomen. Collaborate with the client to determine the position to best assess the perianal region.
- A trauma-informed approach to the objective assessment is necessary considering that areas of the abdomen and the perianal region are being exposed.
- The objective assessment should begin with inspection and palpation related to the oral cavity; inspection, auscultation, palpation, and percussion of the abdomen; and inspection and palpation of the perianal region.
- Health promotion interventions should be developed with the client to address what is important to them.
