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Abstract

Introduction. The revision of the nursing literature published about the Acute Coronary Syndrome shows that four are the big themes that have defined to our studies: the performance protocols, the clinical roads, the clinical cases and the methodology of the nursing process. The disease and not so much the patient's illness has been the authentic main character of our writings. With our present work we seek to go into in those more subjective dimensions of the pain, the illness and the sickness. Methodology. It is a qualitative study of descriptive type, in that we present some of the most significant data in the stories of our patients with Acute Coronary Syndrome.  Results. We have contained the results in seven thematic categories: pain, fear, impact in the family, impact in the labor activity, impact in the recreational activities, impact in the caretaker role and possible causes.  Discussion. The results are compared with other works that have also studied the Acute Coronary Syndrome from diverse perspectives: the sexuality, the verbal describers, the pain, and the testimonies of Mexican women that have passed this same situation.

Introduction

     The Acute Coronary Syndrome (ACS) includes heart disorders which we call unstable angina, heart attack without ST-segment elevation and heart attack with ST-segment elevation. Any of these anomalies is the consequence of a common psychopathological process: the imbalance between the supply and the demand of oxygen by the heart. Another common aspect of these pathologies is their main symptom: thoracic pain.^1,2 If we go through nursing literature on this disorder, there are four subjects that have defined our studies: performance protocols, clinical pathways, clinical cases and the methodology of the nursing process. Most of these pieces of work try to offer tools for our clinical decision as nurses considering the ACS and particularly, considering thoracic pain.
     The protocols we have developed^3-9 reflect how we should act in a quick and effective way from the appearance or the first symptoms until the later stabilization of the patient. Clinical pathways^10-12 give details of the actions that should be taken from the reception of a patient in the Accident and Emergency Department to his admission in the ICU. Clinical cases identify a series of symptoms which can belong to an ACS and they tell us the way we should act.^1,2,6-9 Another of the four subjects already mentioned is that of the nursing process applied to patients with this pathology.^13-15
     All in all, when nurses have dealt with the subject of the ACS, it has almost always been the disease (abnormal functioning of the physiological system, its diagnosis and its treatment) and not its illness (cultural, interpersonal and personal experiences derived from the disease) which plays a leading role in our documents.
     The aim of this work is to go into the more subjective aspects of the disease in more depth, that means, the illness and sickness (social aspect of the disease) of the patients who are admitted into our hospital diagnosed with ACS.¹⁶ Through the compilation of their testimonies, we will show readers the experiences, feelings or the adaptation of these people and their families. In this article we will try to answer the research question: how is the illness of the relatives and patients that are admitted to hospital diagnosed with the Acute Coronary Syndrome?

Methodology

     It is a descriptive qualitative study in which we offer the most significant information about the testimonies of a series of patients with Acute Coronary Syndrome.¹⁷ The place in which our study was carried out was the Special Unit of the Montilla Hospital (Córdoba). It is a polyvalent ICU with capacity to provide care to critical and semi-critical patients.
     The selection of the informants of our sample was intentional and it included patients and relatives with whom researchers have been able to establish fluid communication during their stay in hospital. The only essential requirements have been patients admitted in the Special Unit diagnosed with Acute Coronary Syndrome who were capable of expressing themselves orally and who during their stay were accompanied by either the husband or the wife or by any relative and who voluntarily were willing to take part in this experience. When the saturation principle was reached, no more patients were included. 15 have been the participants.
     The technique used has been in-depth interviews. With the first 5 patients it was an informal conversation interview and since them, different thematic categories were established in our study. With the other 10 patients, the semi-structured interview was used and the main aspects discussed were the thematic categories previously established. The interviews were recorded and patients had previously given their written consent. Interviews were done the day in which patients were discharged from hospital.
     In order to carry out the analysis of the information, every interview was given a code and it was then literally transcribed. The thematic categories were codified and within them, several codified subcategories were established. The information collected from the interviews was manually divided into the categories and subcategories. Apart from the information collected through the interviews, we also used the "participant observation", although in reality the authors have been "observer participants", because the patients that have been studied have been the same ones to whom we provided care every day. The experiences, attitudes and feelings, that we have had access to from this privileged position have been gathered together in a field notebook.

Results

     The profile of the patients with the Acute Coronary Syndrome of our hospital included in our study is a male, 68 years of age, with primary education, married and whose work activity has been mainly physical.

Pain. The localization of pain is broad; the pain is in the chest, head, throat, neck, armpits, arms, forearms, back, sides. Sometimes, the pain starts in the chest and then extends to other parts such as the arms and the neck. In some other cases, the radiation is the other way around.
     When patients describe the pain they feel, they refer to it as something that tightens, that presses. A fine pain that is accompanied by tiredness, nervousness, anxiety, a feeling of breathlessness and that is compared to pincers pressing the heart, to a hanging, to a strong blow, to a pain similar to the one they felt when they were submitted to a cardiac catheterization. They refer to its intensity as unbearable, deep and intense, a pain out of control which prevents them from taking a step forward. The pain lasts from a few minutes to several days. The most intense pain lasts for a few minutes, the bearable pain may last more than one day and the patient may suffer from it almost until the end of his stay in hospital.
     When thoracic pain started, our interviewees were carrying out moderate-intensity activities (going uphill, pushing a trolley, carrying shopping bags), either at work or during their daily activities. In some other cases, the activities were of low or nonexistent activity such as having a shower, going for a walk, having breakfast or even sleeping. In the first episode, pain is attributed to banal causes such as wind or muscle rigidity. In subsequent ischemic episodes, the patient has the feeling that he may suffer a heart attack or an angina pectoris.
     The first thing they did when they were in pain were to stop the activity they were carrying out, to sit down, to take a sip of water, to open a window to let air to come in, to sunbathe with their arms crossed or to go to bed and to sleep. When it does not work, more experienced patients in this kind of disorder resort to a tablet under the tongue. Those accompanying the patients, mainly partners, are the most important people when seeking medical assistance. The decision to move to a health centre sometimes comes from the patient and some others it comes from the person accompanying him.
     From a couple of minutes to an hour is the approximate time that elapses until the arrival to the hospital. On many occasions, there is a step in the middle that consists of going to the nearest health centre. The subjective perception of the passing of time is longer than the objective one. They reach the closest hospital or health care on foot, by the family car, by the company car, by ambulance, by the 061 or by the local police. They feel more secure when they are driven by health transports.

Fear. They are afraid of the pain, the suffering, the loneliness, not recovering from the disease, not to see their families again. They feel anxious and powerless because they see themselves drifted away from their daily lives by something that, as time goes by, is perceived as simple pain.
     Live is experienced as something accepted, as a requirement we all have to meet and that will happen when God disposes. In some other cases there appears in the fist minutes a feeling of imminent death that makes them think that they will not get there in time to get medical assistance.
     Family is always in their thinking. Sometimes pain or symptoms are even hidden not to worry their loved ones. During the first moments, lying down on the stretcher or in the critical care unit, the patient feels alone and he just thinks about their relatives.
     They fear that the after-effects have consequences at work, during their leisure time, while practising sports, when doing housework, when helping their children or during their sexual intercourse. Searching information through health professionals is the main way to combat this fear.
     Our patients trust professionals but the admission to hospital is lived with anguish. They feel alone despite being accompanied by their relatives. Their stay in hospital is associated with the disease rather than with some other positive aspects such as the convalescence or the overcoming of a problem. They are not scared of medical tests or treatments but of staying in hospital. Not knowing how much time there are going to stay there makes them feel anxious.

Impact on the family. Their partners or the people they live with are going through bad times, they feel sad, upset, overwhelmed, powerless and they are afraid. The first episode takes couples by surprise. When it is not the fist time that the ACS appears, husbands and wives are more afraid of the process of the disease than of the consequences of this specific episode.
     Close relatives (parents, children) are not always told about the disease not to worry them, not to hinder their work or to ruin their holidays, not to make them travel long distances or to affect their chronic disease. Their children have their own families and this incident is thought to cause some troubles or to change their daily lives. Their parents are old and this setback is feared to affect their ailments. In some cases, pain is hidden and medical assistance is not sought not to worry them. Partners and relatives seem to suffer more than patients.
     Those who remain together with them during their stay in hospital are their husbands and wives, their children (mainly their daughters), their children-in-law (mainly their daughters-in-law), their neighbours or their close friends. Their parents, parents-in-law, siblings, brothers and sisters-in-law, children, daughters and sons-in-law, friends, neighbours, colleagues visit them occasionally at hospital. Visits are nice but sometimes patients want to have a rest or to be accompanied just by their partners or by their children but not by a lot of people.
     The way of talking and the manners towards the people who come to visit them reflect their surprise by the incident. They speak about their condition, their disease, about pain, medical tests, the treatment, the causes and about work. Sometimes patients avoid talking to them about their disease, except for some exceptional cases.

Impact on work. Our interviewees are field workers, housewives, a panel beater with his own garage, a person in charge of the maintenance of industrial robots, a financial advisor and gunsmith, a grocer in a factory and a builder. Some of them are still working and some others are retired, but they all have some kind of helping or advising relationship with their previous business or tasks, now in the hands of their children. Their physical efforts are related to agriculture and field, building and housework.
     Their mental efforts derive from the responsibility of running their own business (sheet garage, vineyards, consultant's office) or of being in charge of subordinates. We are talking about people who are unwilling to give up this responsibility even once they are retired or during their stay in hospital.
     The feeling of stress does not exist when the work carried out has been mainly physical, although these people feel stressed out when their jobs are or have been based on responsibility.
     With respect to returning to work, some people wanted to start working the same afternoon of the home discharge but, in general, most people prefer to have a few days off. On the one hand, our "physical workers" do not think that this episode is going to have any influence on their way of working. On the other hand, our "responsibility workers" assure that in the future they will have to reduce their stress level at work and that it will depend on themselves and on their way of facing daily work.

Impact on leisure activities. They spend their spare time sewing, making handicrafts, walking, in the church, looking after their plants, doing  odd jobs in their plots of land, doing sports such as bicycling and hunting, being with their small grandchildren, watching football, playing dominoes and cards, reading, watching TV and travelling.
     Patients who carried out physical activities think that they will have to carry them out with less intensity or to change them by others. In some occasions, these physical activities were reduced because of some symptoms such as tiredness and breathlessness that appeared after carrying them out. When leisure activities do not imply a physical component, they do not think about changing them.

Impact on the carer's role. People who care for our patients are their husbands and wives (one of them was pregnant), their children, their grandchildren and their parents. Husbands and wives show that the care given is mutual, which means that it returns to them. The ischemic episode and the admission to hospital make patients feel that care provided to their loved ones is really important and it even enhances their role as carers.
     Possible causes of the ACS. In this session, our patients speak about the circumstances that all along their lives have led or may have led to this episode of ACS. These circumstances can be classified into three groups: situations of loss, psychopathological abnormalities and life habits.
     Situations of loss: Spanish Civil War and the post-war period; early loss of their husbands, so that in the 60's Spanish women had to look after farms, business and family; the death of a sister as a result of a sudden and devastating disease; the deterioration of the health of a sister that at the age of 12 remained tetraplegic and lying on a bed for the rest of her life.
     Psychopathological abnormalities: diabetes, hypercholesterolemia, bronchitis, chronic tiredness after physical activity, heart attack, catheterism, heart operations, colds they have not got rid of yet,  pharmacological treatments.
     Life habits: excessive tension, responsibility or number of hours they spend at work, cigarettes, therapeutic diets that are not followed. Our interviewees define themselves as nervous people worried about apparently banal situations which make them think a lot.
     There are non-smoker men as well as men who have smoked more than two packets a day, although they do not smoke any more. There are also occasional drinkers as well as daily ones but whose consumptions were moderate. They think that tobacco is more dangerous for their hearts than alcohol, although it is thought that alcohol has a higher influence on their nervousness. The women considered in our study had never smoked or drunk.
     Depression is almost constant in the testimonies of these patients. In isolated episodes as well as in relapses that happen again and again during their lifetime. They happened decades ago, a few years ago or are currently happening. They attribute its origin to the loss of their loved ones or to the kind or job, and sometimes they do not attribute it to a specific cause.  

Discussion

     Santos Velasco y cols. in their study about thoracic pain in Accident and Emergency characterize amongst others thoracic pain typical of ischemic heart diseases. At work as well as in the testimonies of our interviewees, it is an "oppressive" pain located on the chest and some other parts and that may radiate to the arms or the neck. Intensity may become "unbearable".
     In the work of Albarrán y cols. about verbal descriptors used by patients to refer to their thoracic pain, they make a difference between sensory and emotional descriptors. Amongst the sensory ones, the oppressive one is the most referred by the participants. Amongst the emotional ones, there are some descriptors very similar to the ones of our interviews, such as "worrying", "unbearable" and "breathlessness".
     Just one of our interviewed patients expressed himself spontaneously about sexuality, asking for information about the way in which this episode was going to influence the intercourse with his partner. He showed the so called "fear not to be able to", pointed out by Casados Dones y cols. in there study.²⁰ As these authors state, it is a subject that patients and professionals do not deal with because of the intimate, private and even shy aspects that we relate to it.
     It is also important to mention the work by the Mexican Susana Salas y cols.²¹ It is a qualitative study (descriptive and with something about interpretation through based theory) in which the expressions of 42 women that experienced thoracic pain were studied. These women were referred to the National Institute of Cardiology Ignacio Chávez, in Mexico. The study population is comprised of Mexican women of middle-low class, with a culture of popular roots based on the Spanish indigenous and colonial mixture. Our population is made up of men and women from the southern countryside of Córdoba. They are middle and middle-high class, farmers, housewives and salary earners, landowners or owners of small shops. The following categories related to pain were established: location, characteristics, intensity, length, causes, meaning, actions taken, people who played a leading role, access to the health system, consequences on the daily life, impact on roles, contextual events and Pandora's box. Our work does not only focus on pain but it mainly focuses on different aspects such as the impact on the family, at work, care to their loved ones or on the possible causes of the ACS.
     We have also included completely new thematic categories such as the one considering fear (to death, to loss the family, to the after-effects, to hospitalization.) or the one considering the impact of the disease on the leisure activities of the patient.

Conclusion

     Through the testimonies and thanks to dealing with patients with the Acute Coronary Syndrome, we have collected information about the way in which these people and their families experience this situation.
     The question we have asked as the beginning: how is the illness of the relatives and the patients that are admitted to hospital diagnosed with Acute Coronary Syndrome? has more than one answer, depending on the patient and the family. Our work shows a relevant approach to the completely subjective aspects of the disease (illness and sickness) and it offers a useful tool for nurses to provide a more comprehensive assistance to this kind of patients-families.
     To conclude, we want to make reference to the critical care area. There are just a few works of this kind. The nurses of these areas (ICUs, Coronary Units, Accident and Emergency) are used to doing more positivist and with quantitative methodology research works, which can be combined and completed with this kind of work with a more phenomenological and qualitative approach.

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