Page 236 - Cardiac Nursing

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212 PA R T III / Assessment of Heart Disease

Table 10-1 ■ DIFFERENTIAL DIAGNOSIS OF EPISODIC CHEST PAIN RESEMBLING ANGINA PECTORIS
Diagnosis Duration Quality Provocation Relief Location Comment
Effort angina 5–15 minutes Visceral (pressure) During effort or Rest, nitroglycerin Substernal radiates First episode vivid
motion
Rest angina 5–15 minutes Visceral (pressure) Spontaneous Nitroglycerin Substernal radiates Often nocturnal
Mitral prolapse Minutes to hours Superficial Spontaneous Time Left anterior No pattern, variable
(rarely visceral) (no pattern) character
Esophageal reflux 10–60 minutes Visceral Recumbency, lack Food, antacid Substernal Rarely radiates
of food epigastric
Esophageal spasm 50–60 minutes Visceral Spontaneous, cold Nitroglycerin Substernal radiates Mimics angina
liquids, exercise
Peptic ulcer Hours Visceral (burning) Lack of food, Food, antacids Epigastric
“acid” foods substernal
Biliary disease Hours Visceral (wax Spontaneous, food Time, analgesia Epigastric radiates Colic
and wane)
Cervical disc Variable (gradually Superficial Head and neck Time, analgesia Arm, neck Not relieved by
subsides) movement rest palpation
Hyperventilation 2–3 minutes Visceral Emotion tachypnea Stimulus removal Substernal Facial paresthesia
Musculoskeletal Variable Superficial Movement, Time, analgesia Multiple Tenderness
palpation

Pulmonary 30 minutes Visceral (pressure) Often spontaneous Rest, time, Substernal Dyspneic
bronchodilator
From Christie, L. G. Jr., & Conti, C. R. [1981]. Systematic approach to the evaluation of angina-like chest pain. American Heart Journal, 102, 899.

person’s beliefs about the causes, symptoms, and treatment of ill- treatment. It should be recorded within quotation marks exactly
ness. Empathy, openness, and interest communicated by the cli- as stated. The chief complaint also should indicate duration, such
nician will enable patients to share their perspectives and beliefs. as “chest discomfort for 2 hours.”
The history-taking process may be the first phase in establish- An asymptomatic patient may present because of a community
ing a therapeutic relationship. The history is a precise, concise, screening activity (e.g., “high blood cholesterol discovered on
chronologic description of the patient’s current health status. The finger-stick last month”) or because of a positive diagnostic result
patient is the primary source of historical data; however, ques- (e.g., “positive calcium score on electron beam CT last week”).
tioning of family members or close friends may provide essential A patient may have more than one chief complaint. Some
information about symptoms and the impact of heart disease on complaints are closely related and may be listed together, such as
family members. For example, the bed partner is more likely than “chest discomfort and weakness for 2 hours.” If complaints are
the patient to provide a history of periodic respiration or sleep ap- unrelated, they should be listed separately in the order of impor-
nea. Review of records from previous encounters is a valuable sec- tance to the patient. In general, “the greater the number of symp-
ondary source of historical data. toms, the less the significance of each.” 3
The primary symptoms of heart disease include chest discom- There are four important points to remember when evaluating
fort, dyspnea, syncope, palpitations, edema, cough, hemoptysis, chest discomfort. 4
and excess fatigue. Heart disease develops slowly, and the patient
1. For a patient who has a history of or who is at risk for develop-
may have a long period of asymptomatic disease and may present
ment of coronary heart disease, always assume that the chest dis-
initially with acute collapse. To describe the health history, a sample
comfort is secondary to ischemia until proven otherwise. This
symptom, chest discomfort, is used throughout this chapter. A sys-
practice is important because unrelieved myocardial ischemia is
tematic approach is useful in differentiating chest discomfort due to
immediately life threatening and can extend infarct size, resulting
serious, life-threatening conditions from those conditions that are
2
less serious or would be treated in a different manner. Table 10-1 in serious complications such as lethal arrhythmia or cardiogenic
shock. Chest discomfort related to other conditions, such as pul-
summarizes conditions associated with chest discomfort.
monary emboli, usually is not as immediately life threatening.
Identifying Information 2.There may be little correlation between the severity of the chest
The patient’s name, the name by which he or she prefers to be called, discomfort and the gravity of its cause. That is, pain is a subjective
his or her age and birth date, and date and time of the interview are experience and depends, in part, on a lifetime of learned reactions
all recorded under identification of the patient. Country of origin, to it. A stoic person may not admit to having much discomfort
religious or cultural group, education, and socioeconomic level con- and yet may be having a large myocardial infarction. Another per-
stitute optional information that may be included. It is assumed that son may express extreme pain and yet may be experiencing stable
all data in the history are obtained from the patient; when this is not angina rather than an acute myocardial infarction. Stress can in-
the case, secondary data sources (e.g., family member, clinical crease pain. Taking into account the patient’s usual response to
records) should be identified. The use of an interpreter should also pain (often obtained from a family member) may help the nurse
be recorded. interpret the patient’s pain response better. In addition, older
adults or people with diabetes may have altered sensory perception
5
Chief Complaint or Presenting Problem and little or no discomfort in the presence of severe disease. When
The chief complaint or presenting problem is the reason the per- present, positive objective signs, such as ST segment shifts on the
son has sought health care and represents his or her priority for electrocardiogram, are clear indicators of the significance of the