Page 235 - Cardiac Nursing

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A A A A Assessment of Heart Disease
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H H H History Taking and Physical Examination
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Barbara S. Levine
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Assessment data, which are obtainedd froom the patient’s history, phys- pa patientt expperiencing a myoccardial infarction requires immmediate, ,
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i ical examination, and diagnostiic tests, are used to fform lulate lcliniical and possiblly life-savingg, medicall and nursing inteerventions (e.g.,
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di diagnnoses, est bli hsh patiient goalls, plan caree, and evaluatee patientt outt- relief off chest discomfort and treatment of arrhythmia) ratther than
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co comes. A completee history and physical examination includes the an extennsive interview. For this patient, asking a few, well-chosen
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same content areas, whether elicited by nurses or physicians. A com- questions regarding chest discomfort using the patient’s descriptors
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l plete hi tstoryy andd physical examination iss impracticall in mostt cliniic l are importantt. In adddition, associated symptoms (such as shortness
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situations. Many hospitals and clinics are using an electronic health of breath or palpitations), drug allergies and reactions, current
record that establishes which data are included.The electronic health medications, history of cardiac and other major illnesses, and
record assures systematic assessment but may constrain the kinds of smoking history should be determined while assessing vital signs
data that are obtained. With freeform records the inclusion of ap- (heart rate and rhythm and blood pressure) and starting an intra-
propriate content areas is determined by the patient’s clinical condi- venous line. As the patient’s condition stabilizes, a more extensive
tion and the purpose and context of the clinical encounter. Specific history should be obtained. Cardiac patients who are not acutely ill
content areas may be investigated in greater detail by clinicians from benefit from a more detailed history and physical examination.
different disciplines, and the data may be used in different ways. A comprehensive history includes the following areas:
Nurses must be able to incorporate historical data into the nursing ■ Identifying information
assessment so the interdependent nursing and medical responsibili- ■ Chief complaint or presenting problem
ties are completed in the correct priority sequence. Conversely, ■ History of the present illness
physicians need to be aware of the data elicited by nurses so the com- ■ Past history
plete database is the foundation for the total plan of care. ■ Review of systems
The provision of culturally appropriate care requires under- ■ Family history
standing of and sensitivity to differences in health beliefs and ■ Personal and social history
practices that reflect cultures or subcultures. The challenge is to be ■ Perceived health status
sensitive to cultural influences that may affect the clinical en- ■ Functional patterns
counter without stereotyping the patient based on limited knowl-
edge of the culture of origin. Three overarching concepts that are The responsibility for obtaining particular portions of the health
influenced by culture and affect the clinical encounter are percep- history varies with practice model and setting. In traditional,
tion of illness or explanatory model, patterns of kinship and deci- hospital-based practice models, the first six areas of the history are
sion making, and comfort with touch. 1 usually obtained by a physician, some data related to personal and
This chapter focuses on history taking and physical examina- social history are obtained by a physician and some by a nurse, and
tion of the patient with heart disease. Emphasis is placed on those data related to perceived health status and functional patterns are
sections of the health history and physical examination that are af- obtained by a nurse. In collaborative practice models, all data may
fected by heart disease. General assessment techniques, with their be obtained by an advanced-practice nurse, or responsibility for all
rationale, are described. Competence in obtaining a history and in areas of data collection may be shared by the physician, advanced-
performing a physical examination cannot be achieved simply by practice nurse, nurse, and other members of the health care team.
reading the material presented. It is vitally important to become The cardiac nurse uses the data to make informed clinical judg-
actively involved in clinical assessment, ideally with a qualified ments, to monitor change over time, to identify patient and family
preceptor. Many hours of practice are required before the begin- learning needs, and to coordinate care across settings.
ning student becomes skilled in assessment techniques.
Health History
CARDIOVASCULAR HISTORY The health history is the patient’s story of his or her diseases,
symptoms, illness experiences, and responses to actual and poten-
Cardiac patients who are acutely ill require a different initial his- tial health problems. Because concepts of health and healing are
tory than do cardiac patients with stable or chronic conditions. A rooted in culture, it is essential to elicit information about the
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