The number leading cause of death among women in the United States (US) is heart disease; it is also the leading cause of disability among women. Currently, “8 million women in the US are living with heart disease; 35,000 are under the age of 65” (Women’s Heart Foundation, 2011). Among American women in 2005 over 36 million were age 55 or older increasing their risk of coronary heart disease (Garvin, Moser, Riegel, McKinley, Doering, & An, 2003). . Coronary heart disease claims the lives of over 200,000 females yearly.
The disease more significantly impacts African-American women than white women. In 2002, their death rate from coronary heart disease was 169. 7 compared to 131. 2 for white women (American Heart Association, 2011). Coronary heart disease is most often caused by a condition called arteriosclerosis, which takes place when a fatty material along with a substance called plaque builds up along the walls of the coronary arteries causing them to become narrow and restrictive.
As the coronary arteries grow rigid and narrow, the combination can restrict the blood flow to the heart causing it to stop or slow down resulting in chest pain, stable angina, shortness of breath, along with other symptoms, eventually resulting in a heart attack (Blank & Smithline, 2002). However, most individuals with coronary artery disease do not display symptoms of the disease for decades, even as it progresses. The first onsets of symptoms are often sudden resulting in myocardial infarctions, also known as heart attacks. American Heart Association, 2011; DeVon, & Zerwic, 2003). Some but not all of the causes of the disorder are the same in men and women. Risk factors that increase the chances of heart disease are: high blood cholesterol levels, high levels of low-density lipoprotein and low levels of high-density lipoproteins, hypertension, diabetes, family history, cigarette smoking, obesity, and physical inactivity (Coronary Artery Disease: Disease/Disorder Overview, 2006). “Every Time we turn around, we find more gender differences; this is why it’s so important to study” (Grady, 2006).
Women with chest pain and other heart symptoms are more prone to have clear coronary arteries when tests are performed unlike with men. In a situation where women do have blocked coronary arteries, they tend to be older than men with similar blockages and have worse symptoms, including more chest pain and disability (Edwards, Albert, Wang & Apperson-Hanson, 2005; Grady, 2006). Women are also more likely than men to develop heart failure, a weakening of the heart muscle that can be fatal. For women suffering severe coronary heart disease, a coronary artery bypass grafting (CABG) could be used to avoid a heart attack.
CABG is used to remove severe blockages in heart arteries that supply blood to the major part of the heart. This treatment is especially effective if the heart has been weakened and not pumping effectively. (Mayo Clinic, 2008) Surgical procedures are the most drastic of measures in treating coronary heart disease. Angioplasty can restore blood flow to the heart if the coronary arteries have become narrowed or blocked. Angioplasty is done on more than 1 million people a year in the United States (Edwards, Albert, Wang & Apperson-Hansen, 2005). When women have bypass surgery or balloon procedures for coronary blockages, they are less likely than men to have good outcomes, and are more likely to suffer from bad side effects. Blood tests also that are reliable when testing on men are less reliable for women. Women also are more likely than men to develop a type of heart failure in response to severe emotional stress. (Grady 2006). Although prevention through healthy lifestyle choices is the best approach to avoiding coronary heart disease, as it is preventable in women, there are treatments available.
Women at risk for coronary heart disease, including those with a history of it in their family, may be prescribed medications to help control symptoms and to prevent damage to the heart. Medications work to increase heart function, relax blood vessels for increased blood flow, lower cholesterol that cause blockage, reduce or prevent blood clots and maintain a normal range blood pressure (WebMD, 2008; Miracle, 2006). The WISE study, women’s ischemic syndrome evaluation also showed some new developments that indicate the insidious type of heart disease, more common in women than men that researchers are just beginning to understand.
The real underlying problem could be a disorder called microvascular disease. This is where the stiffening or narrowing of the smaller arteries that nourish the heart is such tiny vessels that they are too small to show up on angiogram. This causes the small vessels to lose their ability to dilate and increase blood flow to the heart. This phenomena doesn’t’ cause fatty deposits to block the coronary arteries but instead the walls of the vessel become thick and stiff and begin to close. This closure of the now muscular arterioles results in ischemia, lack of blood flow, and over time leads to heart failure and of course the heart attack.
This study was done in 1996, and included 939 women and these findings are a call for a major shift in treatment of women with chest pain or other symptoms and normal angiograms. (New Jersey: Humana Press). It is known that coronary heart disease is preventable and practicing preventative measures will not only lower the risks, but also eradicate this disease (McSweeney & Coon, 2004). Emerging research has been directed towards developing a more complete understanding of gender specific cardiovascular risks, heart health management strategies for women and treatments that consider women’s lifestyles. Women’s Heart Foundation, 2011) Critical knowledge still remains unknown, to better understand coronary heart disease in women, the etiology should be investigated. By examining the origin or causes of a disease so steps can be taken to possibly prevent its progression (King, 2002). Problem Statement Evaluation The research problem addressed is that the leading cause of death in women is heart disease and the differences that exist between men and women.
In the research report, the problem is easily located and clearly stated at the beginning of the report and does have convincing evidence for the study by providing background information on the importance of women and heart disease, diagnosis, treatment, and management. The identification and understanding the differences between men and women are vital especially when they present with chest pain or symptoms of coronary artery disease. This knowledge and education for nursing education, practice and nurses ‘existing level of knowledge is vital to the ongoing practice of health care maintenance and an acute situation. Clinicians can use knowledge of these patterns to detect responses and situations that can decrease decision time in future cardiac events and to educate women about how to respond to cardiac symptoms” (Rosenfield & Lindeure, 2005). This research problem is significant for nursing because nurses need to understand how signs and symptoms of coronary artery disease differ in men and women. Women present with symptoms that are atypical at times and may not look like the textbook classic signs and symptoms. The research also indicates that not only is it women but more so in African-American women.
The risk factors that increase the chances are several and relate to closing the gap of disparities for health care in Healthy People 2010 and the Millennium. Though a conceptual framework was not explicitly stated, the studies clarified women with chest pain and normal angiograms, under treatment, and its possible long term effects were defined as research variables. The proposed solution for closing the gap of knowledge in the treatment would follow the literature regarding the varying differences in treatment between men and women.
This would be a significant contribution to the area that is growing in its understanding. Research that could support an approach to women separately than to men would support change for clinicians all around and including nursing behavior to be the advocate and to address the chest pain in women. Literature Review According to Lefler’s (2002) study, heart disease is the leading cause of death in women and it is also the leading cause of disability among women. As mentioned in the problem statement approximately 8 million women in the US are living with heart disease (Women’s Heart Foundation, 2011).
Studies support that African-American women have a significantly higher incident than white women. It is also confirmed that factors such as socio-economic status and gender play a significant role in the perceptions and understanding of the problem (King, 2005). A significant factor identified is the gender differences. However, sudden death, heart failure, and chest pain symptoms all seem to be related to the gender differences as well (Grady, 2006). The research supports the significant findings in all areas of gender differences from chest pain symptoms, risk factors, heart failure, and sudden death.
But, one of the interesting findings is that most women are prone to have clear coronary arteries on angiogram which is different from men. There’s ongoing studies to show that the underlying cause could be microvascular disease that affects women (Yadon, Kenneth, Marguerite, David, & Alan, 2005). If we want to help prevent deaths from coronary artery disease in women it’s important that the studies performed are pertinent to the gender. This is a significant impact when considering the education and training for all medical personnel as well.
As mentioned by Rosenfeld (2004), the delay in seeking treatment isn’t always due to lack of symptoms but the actual decisions in identifying the differential diagnosis to include coronary artery disease. Often, the signs and symptoms do not reflect the typical coronary artery disease patient; women may only complain of vague pain, or mid-scapular discomfort, maybe abdominal pain but it’s not the classic heaviness in the chest, diaphoresis, right arm numbness, nausea and vomiting. The gender differences need to be considered as well as a normal angiogram (Rosenfeld, 2005 p. 33). DeVon & Zerwic (2003) identified that if prevention starts with education of risk factors for coronary artery disease then it must include gender differences as well. The American Heart Association (2011) states their campaign “Learn and Live” will help save lives. It’s educational and specific to men, women, and most recent what is crucial for African-American women. Although there’s more information and education in medical schools, emergency rooms, and hospitals other than the American Heart Association the word needs to get out there to increase awareness throughout.
Once women understand and take accountability their chances of survival will increase (American Heart Association, 2011). Primary prevention of heart disease typically will be evaluated by a primary physician or internal medicine physician. There’s evidence that supports the typical indicators for women are often not specific enough for women. More often now the female patients that are atypical with risk factors and questionable symptoms are referred to cardiology. The risk stratification is allowing more women to be evaluated sooner.
Often, a cardiac calcium scoring test is done to help identify the risk of atherosclerosis; this is a non-invasive procedure. And, another more common evaluation includes computerized tomography (CT) to scan the heart for coronary calcification in addition to a C-reactive protein (CRP); these two tests are used to help in the prediction of atherosclerosis (Yadon, et. al. , 2005). Theoretical Framework The nursing theory I chose was Lenz et al: Theory of Unpleasant Symptoms (TOUS). The theory was published in the 1990’s then updated later in 1997 nd was developed by 4 nursing researchers; Audry Gift, Renee Milligan, Linda Pugh, and Elizabeth Lenz. They collaborated on various empirical studies and theoretical articles and they shared interest in the nature and experience of different symptoms and in the process of concept and theory development. The TOUS was intended to combine existing information about numerous symptoms. The TOUS was based on the foundation that there were similar experiences among groups experiencing diverse symptoms in dissimilar situations. (Lenz et all, 1997).
This theory has 3 major mechanisms; symptom a person is experiencing, aspects that generate or influence the symptom experience, and the outcome of the symptom experience. The overall structure of the theory has three interrelated categories of factors (physiological, psychological, and situational) that influence predisposition to and manifestation of a given symptom or multiple symptoms and the nature of symptom experience. The symptom experience, in turn, affects the individual performance, which encompasses cognitive, physiological, and social functioning.
The performance outcomes can feed back to influence the symptom experience itself as well as to modify the influencing factors (Liehr & Smith, 2003). According to Huth and Broome (2007) the assumptions of this theory; that persons in varied situations can experience common symptoms and that symptom are the individual phenomena occurring in family and community context. The concepts include symptoms, the influencing factors, and performance as an outcome. In practice; unpleasant symptoms are operationalized by symptom assessment, symptom management, and symptom relief interventions.
In research; symptoms can be described using a symptom scale which measures duration, quality, intensity of the symptom, and the symptom experience. There have been a number of studies using this theory as a conceptual framework that has been conducted. One of the studies looked at the outcomes of pain, medication use, fluid intake, and emesis 24 hr after tonsillectomy. A different study that used associations from the theory of distasteful symptoms was a “correlational” study with methodical case which investigated fatigue and related physiological, psychological, and situational factors in 119 Taiwanese patients (Liu 2006). Theory Analysis
This is a theory that was developed inductively from the specific to the general and from concrete to theoretical. Gift (2009) explained that the TOUS aids nurses to distinguish the need to evaluating numerous indications as well as distinctiveness of the symptom(s), the primary ailment or other origin, as well as the strength, anguish, length, value, and frequency, experienced by the patient caused by these symptom(s). It is clinically appropriate to various patient conditions, as it ought to encourage nurses to reflect on aspects that may persuade several symptoms and the basis of how symptoms cooperate with each other (Lenz et al. 1997). As mentioned, this premise has been used to create an assessment scale. Relating to the problem statement of women and heart disease this model is applicable. The female cardiac patient presenting with the symptoms of chest pain, typical or atypical and the timing, intensity, how much distress is related to the physiologic, psychological, and situational factors of the model. The symptoms that one is experiencing, the factors that are influential in producing or affecting the symptom experience and the consequences of the symptoms experience are all vital pieces in the outcome.
Applying this theory gives the nurse or nurse educator the framework to assess the commonalities of the symptoms among different groups and in different situations. This application and understanding is what’s vital in understanding the differences in heart disease symptoms between men and women. Also, looks at groups and the socioeconomic factors among women and heart disease. This theory started with symptoms as the focal point and is central to the concept. TOUS has focused on subjectively perceived symptoms rather than objectively observable signs.
Symptoms are defined as the “perceived indicators of change in normal functioning as experienced by patients” (Rhodes & Watson 1987, p. 242). Theory Evaluation The theory of unpleasant symptoms does provide a link between nursing practice and interventions and has demonstrated to contribute favorably to outcomes. This is a mid-range nursing theory and can be used in the clinical setting. Nursing working with multiple disciplines and varying specialties in physician practice can utilize this model to assess and communicate to all.
This theory supports nursing and the nursing process while allowing symptoms to be the central focus to communicate with physicians as well. This model allows the use for almost all disease states or if working with a diagnosis able to apply and review retrospectively as well. This theory definitely contributes to the discipline of nursing and adds to our knowledge base. The theory has generated testable hypotheses, guides practice and knowledge, it is complete in terms of subject matter and perspective. The biases or values underlying the theory seem to be explicit and is parsimonious. References
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