Section II: Nursing Health History
In the Philippines, the leading cause of death is heart disease. Most common reasons for individuals to seek emergency and outpatient consult can be cardiovascular-related. Comprehensive assessment along with critical analysis and interpretation of assessment is necessary to determine life-threatening conditions that an individual is experience. However, other cardiovascular-related symptoms like chest pain may be a result of other health problems. In this case, it is necessary that you are not only familiar with the steps in cardiovascular assessment. It is important that you know which assessment step should be prioritized. As you assess the patient, you are beginning to develop an initial impression of what health problem the client is experience.
One of your bases of patient assessment approach is the your health history. In certain cases, we can or cannot perform a complete health history as we need to consider the acuteness and severity of the client’s problem. Your client’s complaints can be:
- Chest pain which is one of the most serious of all patient complaints.
- Palpitations involve an unpleasant awareness of the heartbeat. It can be skipping, racing, fluttering, pounding, or stopping of the heart.
- Shortness of breath is a common patient concern that represent:
- Dyspnea- an uncomfortable awareness of breathing that is inappropriate to a given level of exertion
- Orthopnea- dyspnea that occurs when the patient is supine and improves when the patient sits up
- Paroxysmal nocturnal dyspnea- describes episodes of sudden dyspnea and orthopnea that awaken the patient from sleep
- Swelling or edema - refers to the accumulation of excessive fluid in the extravascular interstitial space
- Fainting, blacking out, or syncope, is a transient loss of consciousness followed by recovery.
As beginning student nurses, it is important to build your competency especially in how to make questions that are understandable and relevant to the client’s complaints. You have to be critical about the questions you will ask to the client and significant others that will promptly help you in the immediate provision of patient care. Remember to always to frameworks to guide you in assessing the client. One of the most commonly taught assessment frameworks in school is the OLDCART method.
- Onset: Identify when the symptoms are first experienced. Determine if it is acute or chronic.
- Location: Ask the patient to locate the affected area to determine single or multiple site affectations.
- Duration: Determine how long has been the symptoms. Determine if it is intermittent or persistent.
- Characteristics: Ask the patient to describe the symptoms and its level of discomfort.
- Associated factors: Determine associated factors and what aggravates the symptom.
- Relieving factor: Determine what relieves the patient from the symptoms.
- Treatment: Ask the patient if consultation has been made, and what medications has been taken.