VOL: 98, ISSUE: 04, PAGE NO: 38
John Albarran, MSc, PGDipEd, DipN, is principal lecturer in critical care, University of the West of England, Bristol
An unexpected episode of chest pain in a patient is a clinical priority and requires the evaluation of key signs and symptoms. This article examines some of the difficulties encountered, the rationale for conducting chest pain assessment and the importance of actively listening to the patient.
Difficulties in assessing chest pain
Patients can develop symptoms of acute chest pain in all health care settings. However, the number of possible causes makes assessment difficult. Acute chest pain may signal an impending cardiac arrest or other life-threatening event, including myocardial infarction (MI), unstable angina, pulmonary embolism, dissecting aneurysm and oesophageal rupture.
The prevalence of acute coronary syndromes, namely unstable angina and MI, means that it is important to act immediately and, until proved otherwise, assume that any patient with acute chest pain has had an MI or ischaemic event. MI is one of the main causes of morbidity and mortality in the UK and any delay in providing life-saving treatment can have a detrimental effect on patient outcomes (Department of Health, 2000).
Identifying patients with MI is not always straightforward, partly because the distribution of nerve fibres supplying the neck, visceral tissues, intrathoracic organs and subdiaphragmatic structures may produce chest pain that mimics the pain associated with MI in terms of radiation, location and sensation. For example, a similar pain signature could be the result of pulmonary, cardiovascular or gastric conditions.
Ascertaining the underlying cause of the pain may be complicated if the patient has had surgery or trauma involving the thorax or intrathoracic organs. In addition, not all patients with MI have typical symptoms. About a fifth, particularly older people and those with diabetes, may have angiographic evidence of coronary artery occlusion but may not have experienced chest pain. This is often referred to as a silent infarction. The converse is also true (Holdright, 1996). For example, in the case of psychogenic chest pain, patients may present with symptoms typical of an acute coronary syndrome but may have normal coronary arteries.
Assessing chest pain can be particularly difficult if patients will not admit that they have symptoms. They may deny having symptoms if they think that a diagnosis may affect their employment prospects. Gender differences can also have a bearing and pain thresholds vary. The under-reporting of chest pain may relate to other variables, including the attitudes of clinical staff and a belief that the nurses are too busy to be interrupted.
Asking the right questions
The most common problem in obtaining an accurate pain assessment is how the questions are asked. For example: ‘Do you have chest pain?’ is a closed question. Rephrasing the question to incorporate the words used by the patient at presentation may result in a more meaningful interaction. Interestingly, pain is a word often used by health professionals but rarely volunteered by patients, who may use a range of alternative words (Treasure, 1998).
Patients may supplement or reinforce verbal descriptions of pain or other symptoms through body language. Non-verbal communication is often used to express physical or emotional sensations. In particular, manual gestures may depict or illustrate both the intensity and qualitative dimensions of pain symptoms (Treasure, 1998; Albarran et al, 2000). For example, clenching the fists over the sternum may denote a feeling of tightness in the chest.
Rationale for assessing chest pain
The reasons for assessing chest pain can be divided into five broad areas:
- To convey humanistic concern;
- To improve and maintain the nurse-patient relationship;
- Accountability and legal implications.
Perhaps the most important and obvious aim is to identify the underlying cause of chest pain. Another fundamental reason is to establish a therapeutic relationship, which is underpinned by unconditional acceptance of patients’ pain symptoms. Through interaction and the process of assessment, nurses can convey humanistic concern for their patients, allay their anxieties and minimise their distress. Generally, for pain management strategies to be effective patients must be involved in their own care. This may include encouraging them to report or record new episodes of pain or deteriorating symptoms.
Finally, nurses must not only assess the nature and intensity of chest pain symptoms but also report and document all relevant details. They are accountable for their actions and could therefore face charges of negligence if they fail to respond appropriately to a complaint of acute chest pain or do not accurately document any care delivered. Such claims are on the increase (Kanojia and Salih, 2000).
Limitations of pain tools
Pain measurement tools - visual analogue or numerical rating scales - are quick and easy to use (Standing, 1997). However, they are limited in that they are concerned only with measuring intensity.
In addition some patients, particularly older people, find it difficult to conceptualise or quantify their pain symptoms on a scale of 0-10. These scales may mean little to people who do not describe their discomfort as pain but as a dullness or an ache, or to those who describe feeling ‘terrified’. It may make more sense to ask them to rank their ‘dullness/ache’.
This approach to measuring pain requires nurses to remain attuned to the words used by patients to articulate the nature of their symptoms.
A more holistic framework that encompasses physical and psychological characteristics as well as intensity scores may enable a more detailed and comprehensive understanding of a patient’s chest pain.
One popular assessment strategy is based on the PQRST mnemonic (Kernicki, 1993; Lazzara and Sellergren, 1996). Although initially time-consuming, it may be a useful template to help nurses discriminate between other causes of chest pain (Box 1, Table 1). It is important that the questions used to elicit information are open-ended.
To be effective and skilled in establishing the nature of chest pain nurses must be committed to learning about the patient’s pain. This requires competency in carrying out a comprehensive assessment of the symptoms, including baseline observations, electrocardiogram interpretation, and listening to and watching for what the patient says and does. It is worth noting, however, that ECG changes for MI may not be clear at the time of presentation or may not be specific, while cardiac enzymes may be detected only after damage to the myocardium has taken place.
Ascertaining the nature of patients’ chest pain is an important role and nurses are ideally placed to initiate this process. Appropriate action may help to enhance clinical status and long-term outcomes in these high-risk groups.
Listening to a patient describe symptoms demands a nurse’s full attention and concentration, which can be difficult in a busy clinical environment. However, only by listening actively can nurses understand patients’ interpretations of their experience. Through listening, nurses also communicate empathy.
Therapeutic listening takes a conscious effort and involves interpreting both verbal and non-verbal cues. It can be emotionally challenging but rewarding.
Therapeutic listening enables nurses to recognise and connect various elements of the patient’s presentation. In doing so they may begin to suspect that the patient has a particular condition, enabling them to pursue a specific line of questioning and carry out additional interventions to identify or eliminate life-threatening causes of acute chest pain.
For example, if a patient presents with a sharp or stabbing pain that radiates to the back, the nurse may suspect a thoracic dissecting aneurysm and would confirm this by examining for equal bounding radial pulses, differences in blood pressure in the left and right arms or evidence of neurological deficit. Further questioning may reveal a previous history of hypertension and/or the presence or absence of specific risk factors.
In this context, each word or gesture can communicate a particular set of ideas which, combined with other clinical data, fosters an understanding that can be validated by further investigations, such as transoesophageal echocardiogram or laboratory results.
Table 2 lists the type of vocabulary patients may use to describe their experiences of angina, MI, pulmonary embolism, dissecting aneurysm or oesophageal rupture.
Descriptions of MI
Over the past few years, analysis of verbal descriptions of MI has received increased attention. Research has shown that patients with subsequently confirmed MI tend to use emotive words when describing their chest pain (Hofgren et al, 1994).
A recent study compared the verbal descriptions of patients with and without MI (Albarran et al, 2000). Although the preliminary findings were inconclusive, the study suggests that in addition to presenting with feelings of tightness, heaviness and pressing sensations, patients with MI are likely to describe their chest pain in terms that convey a strong emotive component. In particular, women in the MI group chose words such as ‘frightening’ and ‘terrifying’ to describe their chest pain more often than men.
When Albarran et al’s (2000) findings are combined with the work of Halm and Penque (1999), it appears that women with MI present differently from men. For example, women may report non-specific descriptions of pain radiating to the back or neck and feelings of light-headedness. It is therefore recommended that nurses anticipate unusual characteristics in women with MI and do not dismiss them as atypical.
The language or metaphors patients use, such as ‘stabbing’, ‘burning’ and ‘like a belt tightening across my chest’, can reflect the quality and intensity of their experience of chest pain and often encompass a sensory or emotive component.
For these reasons nurses must pay attention to the words patients use to describe the acute phase of symptoms. However, isolated individual signs are not helpful, so every clue must be investigated and the assessment must take other relevant findings into account.