Page 237 - Cardiac Nursing

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C HAPTER 1 0 / History Taking and Physical Examination 213
subjective symptom. It is important to realize that the absence of (1) to “the worst pain ever” (10). The severity of pain should be
electrocardiographic criteria for ischemia or infarction does not recorded as a fraction (e.g., 2/10 or 10/10).
eliminate the clinical significance of the chest discomfort. Ask patients to describe the setting and if they were alone or
3. There is a poor correlation between the location of chest dis- with someone when the symptom occurred. If the symptom has
comfort and its source because of the concept of “referred occurred before, ascertain if the setting, circumstances, or the
pain,” which is pain originating in one location but being in- presence of another person is consistent during symptom onset.
terpreted by the patient as occurring in another location. Com- This information may be useful later in counseling or helping a
monly, cardiac discomfort is perceived as being in the arm, jaw, patient gain insight into the development of his or her symptoms.
neck, or epigastric area rather than in the chest. Chest discomfort that is reliably associated with activity (e.g.,
4. The patient may have more than one clinical problem occur- walking up hill) is a specific indicator of cardiac ischemia.
ring simultaneously, particularly if he or she has delayed seek- The patient should be asked to describe any associated symp-
ing medical assistance. toms that always accompany the chief complaint. For example,
palpitations and dizziness might always precede the chest discom-
History of the Present Illness fort. If the patient mentions associated symptoms, these should be
For the symptomatic patient, obtaining the history of the present described in the same manner as the chief complaint (i.e., quality,
illness starts with a more detailed discussion of the chief complaint. quantity, onset, duration). It is important to note whether these
Begin with an open-ended question, such as “Tell me more about associated symptoms occur consistently with the chief complaint
your chest discomfort.” There is a wide range in patients’ abilities to or occur independently at other times.
express thoughts accurately, chronologically, and succinctly. Some Alleviating factors, such as resting, changing position, or taking
patients need guidance more than others. Listen to the patient. It is medication, should be noted. Change in the time it takes for alle-
best to let patients tell their stories in a comfortable manner. How- viating factors to be effective should be identified. For example, if,
ever, patients who appear to be rambling need to be redirected by in the past, the chest discomfort resolved with 5 minutes of rest
clarifying or leading questions. The information that must be ob- and now requires 10 minutes, worsening or a new pathologic
tained when describing any symptom is the time and manner of on- process is suggested. Aggravating factors, such as eating, exercising,
set, frequency and duration, location, quality, quantity, setting, as- or being in a cold climate, also must be recorded. These factors
sociated symptoms, alleviating or aggravating factors, pertinent can provide helpful diagnostic information. To complete the pres-
negative responses, impact of the symptom on usual or desired ac- ent illness history, it is also important to record any pertinent neg-
tivities, and the meaning attributed to the symptom by the patient. ative responses to the interviewer’s questions, such as “The chest
The time of onset should be recorded, when possible, with both discomfort is not made worse by strenuous exercise.” The patient
the date and time (e.g., “9 PM on December 22nd”). When the should be specifically asked about palpitations, dizziness, syncope,
patient presents with chest discomfort, it is essential to know how dyspnea, orthopnea, and paroxysmal nocturnal dyspnea, if these
long the discomfort has been present and if it has been present symptoms have not already been described.
continuously since onset. The manner of onset is the way in which Impact of the symptom on usual or desired activities should be
the symptom began. For example, discomfort may begin suddenly explored. Some people with recurrent chest discomfort reduce
and reach maximum intensity immediately, or there may be a their activity over time to try and prevent chest discomfort. It is
growing awareness of the discomfort over time. Frequency and du- essential that clinicians understand how the symptom or disease
ration should be stated specifically rather than generally (e.g., has affected the patient’s activity and perceived quality of life.
“once a week,” “once a day,” or “more than three times a day”). Throughout the interview, the nurse observes the patient care-
Likewise, patients should be assisted to express the duration of the fully and may begin to understand the meaning the illness has for
discomfort, as in “2 minutes,” “15 minutes,” or “1 hour.” For pa- the patient. The personal meaning of the illness can amplify or re-
tients with a history of angina, it is also important to determine if duce the symptom experience and course of action. When inter-
there has been any change in frequency or duration of chest dis- viewing members of a culture not one’s own, ask “Can you tell me
comfort, which suggests worsening of the underlying disease. what caused your illness?” and about the use of home remedies,
Ask the patient to describe the exact location of the symptom foods, or traditional healers. 7
by pointing to it. Cardiac pain is diffuse, and the patient often The results of diagnostic or laboratory testing specifically re-
rubs a hand over the sternum and precordium. Chest pain that lated to heart disease are included in the history ofpresent illness.
can be precisely located with a fingertip is usually related to chest Prior cardiac events (e.g., coronary artery bypass surgery or my-
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wall abnormalities. If the pain radiates, the patient should trace ocardial infarction) are included also.
its path with a fingertip. The quality of a symptom refers to its Cardiovascular risk factors and current activity may be added
unique characteristics, such as color, appearance, and texture. in a separate paragraph to the conventional content of the history
Chest discomfort is so subjective that its quality is particularly dif- of present illness. Risk factors for coronary heart disease are dis-
ficult to describe. Thus, whenever possible, it is important to use cussed in Chapter 32.
the patient’s own words (in quotation marks). Angina means Sample questions that may be used in assessing the patient
tightening, and the discomfort associated with angina may be de- with acute or recurrent chest discomfort are listed below. Similar
scribed as “pressing,” “squeezing,” “tightening,” “strangling,” or questions may be generated to assess patients with other symp-
6
“constricting.” The patient’s response to the symptom also toms. However, it is important to phrase the questions according
should be recorded (e.g., “It makes me stop what I’m doing and to the appropriateness of the situation and logically to pursue ar-
sit down,” or “I can continue my activities without stopping”). eas where further clarification is necessary.
Quantity refers to the size, extent, or amount of the symptom.
The quantity of the chest discomfort is described in terms of its ■ When exactly do you get the discomfort? Are you having dis-
severity. Again, quantity is extremely subjective and might be comfort now?
rated best on a 10-point scale, ranging from “barely noticeable” ■ What were you doing when the chest discomfort occurred?