326 Exam 3: MOD 9; Subjective Assessment Chapter 21
FIVE A's of smoking cessation:
Ask about current smoking status. Advise to quit and provide information on how beneficial quitting is. Assess willingness to quit. Assist with finding resources and making a plan to quit. Arrange for follow-ups to help the patient follow through and quit.
Subjective Assessment: Chest Pain COLDSPA Question:
Character: Describe your chest pain (stabbing, burning, crushing, squeezing, or tightness). Onset: When did it start? Location: Where is the pain? Does it radiate to any other area? Where? Duration: How long does the pain last? How often do you experience the pain? Severity: Rate the pain on a scale of 0-10, with 10 being the worst possible pain. Patterns: What brings on the pain (activity, stress, eating, sexual activity, weather change, extreme cold or heat, lying flat, resting)? What relieves the pain (nitroglycerin, rest)? Associated Factors: Do you have any other symptoms with this pain (shortness of breath [dyspnea], perspiration [diaphoresis], pale clammy skin, nausea, vomiting, or heart beat skips or speeds up)?
Subjective Assessment: Chest Pain Rationale:
Chest pain can be cardiac, pulmonary, muscular, or gastrointestinal in origin. Angina (cardiac chest pain) is usually described as a sensation of squeezing around the heart; a steady, severe pain; and a sense of pressure. It may radiate to the left shoulder and down the left arm or to the jaw. Diaphoresis and pain worsened by activity are usually related to cardiac chest pain.
Subjective Assessment: (Q) Lifestyle and Health Practices Do you smoke? How many packs of cigarettes per day and for how many years? Are you trying to or interested in trying to quit smoking?
Cigarette smoking greatly increases the risk of heart disease (Box 21-4). If the client is trying to quit, then use the five As of smoking cessation (Box 21-5) to help the client stop smoking. Even a brief intervention can significantly increase the rates at which clients stop smoking
Subjective Assessment: Chest Pain Question:
Do you experience chest pain? If the client answers yes, use COLDSPA to explore the symptoms Chest pain may also be due to pulmonary, gastrointestinal, musculoskeletal, or psychogenic problems.
Subjective Assessment: (Q) Tachycardia and Palpitations
Does your heart ever beat faster? Does your heart ever skip beats, or have extra beats? When does this occur and how long does it last? What makes this better or worse?
Subjective Assessment: (Q) Other symptoms: Do you have frequent heartburn? When does it occur? What relieves it? How often do you experience it?
Subjective Assessment: (R) Cardiac pain may be overlooked or misinterpreted as gastrointestinal problems. Gastrointestinal pain may occur after meals and is relieved with antacids. Cardiac pain may occur anytime, is not relieved with antacids, and worsens with activity.
Subjective Assessment: (Q) Other symptoms: Do you experience dizziness?
Subjective Assessment: (R) Dizziness may indicate decreased blood flow to the brain due to myocardial damage. However, there are several other causes for dizziness such as inner ear syndromes, decreased cerebral circulation, and hypotension.
Subjective Assessment: (Q) Other symptoms: Do you have difficulty breathing (dyspnea) or shortness of breath? When does this occur? What activities cause you to be short of breath? Do you have difficulty breathing when you are lying down? How many pillows do you use to sleep? Does the difficulty in breathing wake you up at night?
Subjective Assessment: (R) Dyspnea may result from congestive heart failure, pulmonary disorders, coronary artery disease, myocardial ischemia, and myocardial infarction (MI). Dyspnea may occur at rest; during sleep; or with mild, moderate, or extreme exertion. Orthopnea is the need to sit more upright to breathe easily due to fluid accumulation in the lungs. Waking up from dyspnea during the night (paroxysmal nocturnal dyspnea) is seen with heart failure due to redistribution of fluid from the ankles to the lungs when one lies down at night. The failing heart cannot accommodate the increased load.
Subjective Assessment: (Q) Other symptoms: Do you tire easily? Do you experience fatigue? Describe when the fatigue started. Was it sudden or gradual? Do you notice it at any particular time of day?
Subjective Assessment: (R) Fatigue may result from compromised CO. Fatigue related to decreased CO is worse in the evening or as the day progresses, whereas fatigue seen with depression is ongoing throughout the day.
Subjective Assessment: (Q) Other symptoms: Do you cough up mucous? When does it occur? Describe the appearance.
Subjective Assessment: (R) Fluid accumulation in the lungs from heart failure can cause one to cough up white- or pink-tinged sputum.
Subjective Assessment: (Q) Other symptoms: Do you wake up at night with an urgent need to urinate (nocturia)? If so, how many times each night?
Subjective Assessment: (R) Increased renal perfusion during periods of rest or recumbent positions may cause nocturia, which occurs with heart failure.
Subjective Assessment: (Q) Lifestyle and Health Practices
Subjective Assessment: (R) Lifestyle and Health Practices
Subjective Assessment: (Q) Lifestyle and Health Practices Describe what you usually eat in a 24-hour period.
Subjective Assessment: (R) Lifestyle and Health Practices A diet high in fat and cholesterol and low in fruits and vegetables increases the chance of fatty plaque formation in the coronary vessels, which increases the chance of cardiovascular disease.
Subjective Assessment: (Q) Lifestyle and Health Practices How important is having a healthy heart to your ability to feel good about yourself and your appearance? What fears about heart disease do you have?
Subjective Assessment: (R) Lifestyle and Health Practices A person's feeling of self-worth may depend on the ability to perform usual daily activities and fulfill the usual roles. Of more than 1,000 adult U.S. women surveyed, 9.7% identified heart disease as the disease they fear most
Subjective Assessment: (Q) Lifestyle and Health Practices Do you exercise? What type of exercise and how often?
Subjective Assessment: (R) Lifestyle and Health Practices A sedentary lifestyle is a known modifiable risk factor contributing to heart disease. Aerobic exercise three times per week for 30 minutes is more beneficial than anaerobic exercise or sporadic exercise in preventing heart disease.
Subjective Assessment: (Q) Lifestyle and Health Practices How much alcohol do you consume each day/week?
Subjective Assessment: (R) Lifestyle and Health Practices Excessive intake of alcohol has been linked to hypertension. Three drinks at one sitting raises blood pressure. More than two drinks per day for men under 65 or one drink per day for women and men over 65 is associated with high blood pressure and other diseases
Subjective Assessment: (Q) Lifestyle and Health Practices Describe your daily activities. How are they different from your routine 5 or 10 years ago? Does fatigue, chest pain, or shortness of breath limit your ability to perform daily activities? Describe. Are you able to care for yourself?
Subjective Assessment: (R) Lifestyle and Health Practices Heart disease may impede the ability to perform daily activities. Exertional dyspnea or fatigue may indicate heart failure. An inability to complete ADLs may necessitate a referral for home care.
Subjective Assessment: (Q) Lifestyle and Health Practices How many pillows do you use to sleep at night? Do you get up to urinate during the night? Do you feel rested in the morning?
Subjective Assessment: (R) Lifestyle and Health Practices If heart function is compromised, CO to the kidneys is reduced during episodes of activity. At rest, CO increases, as does glomerular filtration and urinary output. Orthopnea (the inability to breathe while supine) and nocturia may indicate heart failure. In addition, these two conditions may also impede the ability to get adequate rest.
Subjective Assessment: (Q) Lifestyle and Health Practices Has your heart disease had any effect on your sexual activity?
Subjective Assessment: (R) Lifestyle and Health Practices Many clients with heart disease are afraid that sexual activity will precipitate chest pain. If the client can walk one block or climb two flights of stairs without experiencing symptoms, it is generally acceptable for the client to engage in sexual intercourse. Nitroglycerin can be taken before intercourse as a prophylactic for chest pain. In addition, the side-lying position for sexual intercourse may reduce the workload on the heart.
Subjective Assessment: (Q) Lifestyle and Health Practices What type of stress do you have in your life? How do you cope with it?
Subjective Assessment: (R) Lifestyle and Health Practices Stress has been identified as a possible risk factor for heart disease.
Subjective Assessment: (Q) Personal Health History: Have you ever had an electrocardiogram (ECG)? When was the last one performed? Do you know the results?
Subjective Assessment: (R) Personal Health History: A prior ECG allows the health care team to evaluate for any changes in cardiac conduction or previous MI.
Subjective Assessment: (Q) Personal Health History: Have you ever had rheumatic fever?
Subjective Assessment: (R) Personal Health History: Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are significant public health concerns around the world (World Health Organization, 2018). Rheumatic carditis develops after exposure to group A beta hemolytic streptococci and results in inflammation of all layers of the heart, impairing contraction and valvular function.
Subjective Assessment: (Q) Personal Health History: Do you take medications or use other treatments for heart disease? How often do you take them? Why do you take them?
Subjective Assessment: (R) Personal Health History: Clients may have medications prescribed for heart disease but may not take them regularly. Clients may skip taking their diuretics because of having to urinate frequently. Beta blockers may be omitted because of the adverse effects on sexual energy. Education about medications may be needed.
Subjective Assessment: (Q) Personal Health History: Have you been diagnosed with a heart defect or a murmur?
Subjective Assessment: (R) Personal Health History: Congenital or acquired defects affect the heart's ability to pump, decreasing the oxygen supply to the tissues.
Subjective Assessment: (Q) Personal Health History: Have you ever had a lipid profile blood test? Based on your last test, do you know what your cholesterol levels were?
Subjective Assessment: (R) Personal Health History: Dyslipidemia presents the greatest risk for developing CAD. Elevated cholesterol levels have been linked to the development of atherosclerosis.
Subjective Assessment: (Q) Personal Health History: Have you ever had heart surgery or cardiac balloon interventions?
Subjective Assessment: (R) Personal Health History: Previous heart surgery may change the heart sounds heard during auscultation. Surgery and cardiac balloon interventions indicate prior cardiac compromise.
Subjective Assessment: (Q) Personal Health History: Do you monitor your own HR or blood pressure? When did you last have your blood pressure checked by a health care professional?
Subjective Assessment: (R) Personal Health History: Self-monitoring of HR or blood pressure is recommended if the client is taking cardiotonic or antihypertensive medications. A demonstration is necessary to ensure appropriate technique. The AHA (2019b) recommends that blood pressure screening start at age 20 (at each health care visit and at least once a year if blood pressure is less than 120/80 mmHg), fasting lipoprotein profile (cholesterol and triglycerides; baseline) every 4-6 years.
Subjective Assessment: (Q) Other symptoms: Do you experience swelling (edema) in your feet, ankles, or legs? When did this begin? What time of day do you have this swelling? Is it in one or both legs?
Subjective Assessment: (R) Venous insufficiency is the most common cause of peripheral edema. A sudden onset of edema in one leg with pain may be due to a blood clot in that leg (deep vein thrombosis). Bilateral edema in both lower extremities at night is seen in heart failure due to a reduction of blood flow out of the heart, causing blood returning to the heart to back up in the organs and dependent areas of the body.
Subjective Assessment: (R) Tachycardia and Palpitations
Tachycardia may be seen with weak heart muscles, an attempt by the heart to increase CO. Palpitations may occur with an abnormality of the heart's conduction system (arrhythmias) or during the heart's attempt to increase CO by increasing the HR. Palpitations may cause the client to feel anxious.
