Biomedical subjects
Julie Johnson Zerwic
Publications and source records attributed to Julie Johnson Zerwic.
Reducing delay in seeking treatment by patients with acute coronary syndrome and stroke: a scientific statement from the American Heart Association Council on cardiovascular nursing and stroke council.
Patient delay in seeking treatment for acute coronary syndrome and stroke symptoms is the major factor limiting delivery of definitive treatment in these conditions. Despite decades of research and public education campaigns aimed at decreasing patient delay times, most patients still do not seek treatment in a timely manner. In this scientific statement, we summarize the evidence that (1) demonstrates the benefits of early treatment, (2) describes the extent of the problem of patient delay, (3) identifies the factors related to patient delay in seeking timely treatment, and (4) reveals the inadequacies of our current approaches to decreasing patient delay. Finally, we offer suggestions for clinical practice and future research.
The influence of age on acute myocardial infarction symptoms and patient delay in seeking treatment.
A secondary analysis was conducted from data gathered from 239 patients with acute myocardial infarction presenting to the emergency departments of three hospitals to explore the influence of age on delay time, experienced symptoms, and factors predicting a delay of >1 hour. During hospitalization, a structured interview about the patients' experience before hospital admission was completed and their medical records were reviewed. The median delay before seeking treatment was not significantly different between older (2.5 hours) and younger patients (2.1 hours). Older patients were significantly less likely to report classic pain in the center of the chest and other associated symptoms such as sweating and nausea; they also used fewer words to describe their discomfort compared with younger patients. Independent predictors of longer delay were: contacted physician, lacked similarity between experienced and expected symptoms, did not use 911 (older adults), lived alone, and contacted physician (younger adults). Primary care providers need to be aware that elderly persons are more likely to have mild or ambiguous acute myocardial infarction symptoms and education is needed for elderly persons regarding not only acute myocardial infarction symptoms but also rapid, action-centered decisions to attribute symptoms to heart problems and initiate ambulance use.
Symptoms of unstable angina in patients with and without diabetes.
Patients with diabetes experience cardiac autonomic neuropathy that may affect the way they perceive the symptoms of unstable angina (UA). The purpose of this study was to examine symptom differences in patients with and without diabetes during an episode of UA. A convenience sample of 50 women and 50 men were recruited. Patients with diabetes were more likely to have a history of hypercholesterolemia (83% vs. 60%), prior history of heart disease (85% vs. 65%), and prior angiogram (85% vs. 67%). Patients with diabetes reported having less nausea (20% vs. 40%), less squeezing (25% vs. 48%) and less aching (25% vs. 45%) type pain, and more hyperventilation (27.5% vs. 11.7%). Other cardiac symptoms were similar between the groups. Further study of symptom presentation in patients with diabetes is warranted given their high levels of morbidity and mortality from cardiac disease.
Typical and atypical symptoms: diagnosing acute coronary syndromes accurately.
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Conceptual model of health-related quality of life.
PURPOSE: To revise the Wilson and Cleary model of health-related quality of life (HRQoL), with suggestions for applying each of the components, and to facilitate the use of HRQoL in nursing and health care. ORGANIZING CONSTRUCT: HRQoL, based on relevant literature over the past 20 years. METHODS: The original model was revised in three substantive ways: (a) indicating that biological function is influenced by characteristics of both individuals and environments; (b) deleting nonmedical factors; and (c) deleting the labels on the arrows that tend to restrict characterization of the relationships. FINDINGS: Theoretical background is provided for each of the major components of the model, and examples of instruments to measure them, were added. CONCLUSIONS: In quality-of-life research, the current challenge is to devise models to clarify the elements of health-related quality of life (HRQOL) and the causal relationships among them. This revision of Wilson and Cleary's model includes a taxonomy of the variables that often have been used to measure HRQoL. This revision should be useful in research and clinical practice.
Differences in the symptoms associated with unstable angina and myocardial infarction.
The purpose of this study was to examine whether the symptoms experienced by patients with unstable angina (UA) differed from the symptoms experienced by patients with myocardial infarction (MI). Data were obtained from two studies: one examining the symptoms of MI (n=238) and one examining the symptoms of UA (n=100). Interviews were conducted after hospital admission at three medical centers in the Midwest. There were no differences between patients with MI or UA in age, gender, or race. The patients experiencing MI reported significantly more nausea (46% vs. 32%), vomiting (19% vs. 2%), indigestion (42% vs. 16%), and fainting (9% vs. 2%). The patients experiencing UA reported significantly more chest discomfort (97% vs. 87%), lightheadedness (52% vs. 39%), numbness in the hands (43% vs. 28%), and neck discomfort (31% vs. 13%). Patients with MI rated the peak intensity of the chest discomfort higher than patients with UA (mean 8.4 vs. mean 7.7).
Is the medical record an accurate reflection of patients' symptoms during acute myocardial infarction?
Documentation of symptoms in the medical record provides clinicians and researchers with valuable information about the patient's experience during acute myocardial infarction (AMI). To examine the consistency between the patient's reported symptoms and the medical record, 215 patients were interviewed and their medical records examined for information about their admission symptoms. Chest pain was the most frequently reported and recorded symptom, and there was good agreement between the patient's report and the medical record. Although fatigue was the second most frequently reported symptom by patients, it was rarely documented in the medical record. Time of symptom onset was identified by 87.9% of patients but only documented in 60.5% of medical records. Clinicians may be recording those symptoms that support the AMI diagnosis and not those perceived to be less relevant. Findings suggest that the medical record is an inaccurate and inadequate source of information about patients' actual experience of AMI symptoms.
Noncompliance in heart transplantation: a role for the advanced practice nurse.
Many organ transplant recipients experience organ rejection because they are noncompliant with the requirements of the health care regimen. The advanced practice nurse is in an ideal position to assess predictors of noncompliance as well as to implement interventions to enhance patient compliance. The purpose of this paper is to present a case study of a young female heart transplant recipient whose death due to organ rejection was related to noncompliance. The role of the advanced practice nurse in reducing noncompliance is identified and relevant nursing interventions are discussed.
Stroke. Risks, recognition, and return to work.
1. The two major classifications of stroke are ischemic and hemorrhagic. Ischemic strokes account for 75% of all strokes and result from the complete occlusion of an artery. Hemorrhagic strokes, often caused by aneurysm or hypertension, are caused by the rupture of a cerebral blood vessel and bleeding into the surrounding tissue. 2. The signs and symptoms of stroke may include unilateral weakness or paralysis, a sagging of one side of the face, double or blurred vision, vertigo, numbness or tingling, and language disturbances. 3. Management of ischemic stroke may include thrombolytic agents (e.g., heparin, warfarin) if the individual is treated within 6 hours after the onset of symptoms. Diagnostic tests may include, computed tomography scan, transesophageal echocardiagraphy, Doppler ultrasonography, and electrocordiography. 4. Occupational health nurses can be actively involved in helping workers modify their risks for stroke, developing and implementing an action plan if an individual is experiencing a stroke, and facilitating the individual's reentry into the worksite after rehabilitation is completed.
The Center for Research on Cardiovascular and Respiratory Health: the development of a National Institute of Nursing Research-funded center.
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Symptoms of acute coronary syndromes: are there gender differences? A review of the literature.
Evidence has begun to accumulate that suggests there may be gender differences in the presenting symptoms of acute coronary syndromes (ACS). Identification of gender differences has implications for both health care providers and the general public. Women should be instructed as to the symptoms expected with ACS on the basis of evidence obtained from studies that include both sexes. Twelve studies that identified symptoms of ACS for both women and men were identified through a review of the literature. In several of the studies, which included all types of ACS, women had significantly more back and jaw pain, nausea and/or vomiting, dyspnea, indigestion, and palpitations. In a number of the studies, which solely sampled patients with acute myocardial infarction, women demonstrated more back, jaw, and neck pain; nausea and/or vomiting; dyspnea; palpitations; indigestion; dizziness; fatigue; loss of appetite; and syncope. Men reported more chest pain and diaphoresis in the myocardial infarction sample. Results of these studies showed that women and men experienced the same symptoms with ACS. However, in some studies there were gender differences in the proportion of symptoms. Given the current state of the science, definitive conclusions regarding gender differences in the symptoms of ACS cannot be drawn. Further study is urgently needed to clarify and expand on these findings.
Perceptions of symptoms of myocardial infarction related to health care seeking behaviors in the elderly.
Research on acute myocardial infarction (AMI) suggests that older persons may delay significantly longer than younger persons between the first appearance of symptoms of AMI and seeking treatment and that this delay is associated with increased morbidity and mortality. The factors that potentially influence delay in older persons can be grouped into 4 categories: (a) symptom attribution to aging, (b) symptom severity and duration, (c) symptom attribution to comorbid and chronic conditions, and (d) previous experience with cardiac problems. This article explores the link between symptom interpretation and health care seeking behaviors in elderly patients with AMI as it relates to delay in seeking treatment for AMI. Potential nursing interventions are presented.
The symptoms of unstable angina: do women and men differ?
BACKGROUND: Research has shown that there are differences between women and men in the epidemiology, presentation, and outcomes of coronary heart disease. OBJECTIVES: The purpose of this study was to determine if there were sex differences in the symptoms of unstable angina (UA) and if so, to determine if these differences remained after controlling for age, diabetes, anxiety, depression, and functional status. METHOD: This descriptive study used a nonexperimental, quantitative design. A convenience sample of 50 women and 50 men, hospitalized with UA, were recruited from an urban and a suburban medical center. Instruments included the Unstable Angina Symptoms Questionnaire (UASQ), the Hospital Anxiety and Depression Scale (HADS), and the Canadian Cardiovascular Society (CCS) classification of angina. RESULTS: Multivariate analysis indicated that women experienced significantly (p <.05) more shortness of breath (74% vs. 60%), weakness (74% vs. 48%), difficulty breathing (66% vs. 38%), nausea (42% vs. 22%), and loss of appetite (40% vs. 10%) than men. After controlling for age, diabetes, anxiety, depression, and functional status, women were still more likely than men to report weakness (p =.03), difficulty breathing (p =.02), nausea (p =.03), and loss of appetite (p =.02). Chi-square analysis of symptom descriptors revealed that women disclosed more (p <.05) upper back pain (42% vs. 18%), stabbing pain (32% vs. 12%), and knifelike pain (28% vs. 12%). Women also had a significantly higher incidence of depression (22% vs. 2%, p <.01). CONCLUSIONS: Findings suggest that women and men have similar symptoms during an episode of UA, however, a higher proportion of women have less typical symptoms.
Treatment seeking for acute myocardial infarction symptoms: differences in delay across sex and race.
BACKGROUND: Patients experiencing an acute myocardial infarction are known to delay seeking treatment between 2 and 4 hours. This delay is problematic because individuals who receive treatment 2 or more hours after the onset of symptoms are less likely to benefit from emergent reperfusion techniques. Persons most likely to delay seeking treatment for an acute myocardial infarction and their reasons have not been clearly identified. OBJECTIVE: The purpose of this study was to identify the effect of selected demographic, clinical, cognitive, and environmental variables on the length of the time of delay. In addition, the study was designed to identify whether women delayed longer than men, and whether African Americans delayed longer than non-Hispanic Whites during an acute myocardial infarction. METHOD: A structured interview was conducted in a convenience sample (N eq> 212) of African American and non-Hispanic White patients hospitalized after acute myocardial infarction. Patients were asked detailed information about the sequence of events prior to the acute myocardial infarction, and the symptoms experienced. Medical records were examined for clinical information. RESULTS: Women did not delay significantly longer than men (2.0 vs. 2.5 median hours). African Americans delayed significantly longer than non-Hispanic Whites (3.25 hours vs. 2.0 median hours). Race did not contribute unique variance to delay time in a simultaneous multiple regression analysis; however, race was a significant predictor variable in whether or not participants sought treatment within the first hour after the onset of symptoms. The variance in delay time for African American and Non-Hispanic White men and women that could be explained by the predictor variables ranged from 23-47%. CONCLUSIONS: The reasons for delay differed in part by sex and race.
Knowledge of symptom clusters among adults at risk for acute myocardial infarction.
BACKGROUND: Individuals need to recognize acute myocardial infarction symptoms in order to seek treatment promptly. Previous acute myocardial infarction symptom studies asked subjects to identify single symptoms from a list. However, people think about illnesses or respond to symptoms by considering groups or clusters of symptoms. OBJECTIVE: To use Q methodology to identify the cluster of symptoms that individuals at high risk for acute myocardial infarction and their significant others believe to be associated with acute myocardial infarction. METHODS: A Q sort instrument that represented a range of symptoms was developed after analysis of 140 interviews with acute myocardial infarction survivors. Individuals with known coronary artery disease or their significant others (n = 63) sorted the resulting 49 statements describing acute myocardial infarction into "most expected" and "least expected" categories. By-person factor analysis was used. RESULTS: Four factors were identified that described different presentations of acute myocardial infarction symptoms. Respondents loaded on the following factors: Factor 1 (traditional symptoms), Factor 2 (symptoms possibly related to gastrointestinal disorders), Factor 3 (nonspecific symptoms), and Factor 4 (a variation on traditional symptoms). This four-factor solution accounted for 36% of the total variance. CONCLUSIONS: The Q methodology showed that people with known coronary artery disease and their significant others had varied expectations of acute myocardial infarction symptoms. New and various strategies need to be developed to help patients accurately identify acute myocardial infarction symptoms.