i thought that this might be useful to the new nurses going to the "cardiac floors", as a quick reference:
chest pain assessment for non-cardiac nurses
acute coronary syndromes (acs) are imbalances between myocardial oxygen supply and demand (oxygen available vs. oxygen used). prompt coronary reperfusion limits myocardial necrosis, preserves left ventricular (lv) function and reduces mortality. failing to recognize and respond to symptoms has resulted in delays in care outside of the hospital setting. rapid reperfusion remains the patient's primary treatment and therefore early assessment of chest pain in non-cardiac areas of hospitals is of primary importance.
women, diabetics, and the elderly more commonly present with atypical chest pain symptoms and should be evaluated for ischemia despite unusual symptoms. more than half a million women die each year from cardiovascular disease, making it the number 1 killer of women in the united states. one-third of patients presenting to hospitals with confirmed acute mi (of 430,000) had no chest pain (cp). absence of cp (or atypical cp) is important for therapy and prognosis, patients without cp were much less likely to be accurately diagnosed on admission and therefore treated with the appropriate therapy.
your goal… is to determine the cause of chest discomfort and initiate appropriate therapy. initial assessment of the patient situation and management must be rapid, systematic, and evidence-based. initial evaluation distinguishes among the potential causes of chest pain:
* acute coronary syndrome - myocardial infarction (mi) or unstable angina (usa)
* stable angina pectoris - follows a precipitating event, usual severity, typical dose of ntg relieves pain
* nonischemic chest pain, including life-threatening conditions such as aortic dissections, pulmonary embolism, or esophageal rupture
the goals of prompt action are to:
* increase oxygen delivery, increase diastolic filling time - more time in relaxation phase coronary vasodilation - early reperfusion oxygen - minimum of 6 hours of onset of chest pain revascularize - fibrinolytics, ptca, cabg - provide blood flow thus oxygen back to heart
* decrease oxygen consumption
decrease heart rate
* manage hemodynamics
* assess for cardiogenic shock
immediate management of the chest pain patient: (assessment of pain occurs while performing skills and procedures)
* assess pain
* know the patient's risk of acs - know your patient's pertinent history, admitting diagnosis, procedures/diagnostics, lab work, etc. are they at risk for a cardiac event? vs. pe, aneurysm, esophageal rupture?
* airway, breathing, and circulation assessed - remember your abcs!
* obtain 12 lead ecg
* resuscitation equipment to patient, nearby - abcs!
* cardiac monitor attached
* oxygen given
* iv access, obtain blood work - cardiac enzymes/troponins and electrolytes
* aspirin 162-325 mg (unless contraindicated)
* nitrates and morphine (unless contraindicated)
assess your patient's pain: (use the opqrst mnemonic)
* onset - ischemic chest pain is typically gradual in onset with a coming and going of intensity
* provocation and palliation - typically provoked by activity like exercise, it doesn't change with respiration or position
* quality - characterized as a discomfort more than pain, difficult for the patient to describe, squeezing, tightness, pressure, constriction, crushing, strangling, burning, heartburn, fullness in the chest, band-like, knot in center of chest, lump in throat, ache, heavy weight on chest (elephant), bra too tight, or toothache (radiation to lower jaw). (levine sign - places clenched fist in center of chest)
* radiation - ischemic pain radiates to other parts of the body including the upper abdomen (epigastrium), shoulders, upper and forearms, wrist, fingers, neck and throat, lower jaw and teeth (not upper jaw), infrequently to the back (more common in aneurysms)
* site - diffuse discomfort that may be difficult to localize, pointing to a specific area with a single finger is usually noncardiac
* time course - angina is usually 2 - 5 minutes and relieved by rest or ntg. patients with acs may have cp at rest and duration is varies lasting usually longer than 30 minutes.
*associated symptoms - shortness of breath reflecting pulmonary congestion (possible diastolic dysfunction), belching, nausea, indigestion, vomiting, diaphoresis, dizziness, lightheadedness, clamminess, and fatigue
diagnostics (concurrently obtain)
* history - patient and family history of risk factors
look for hyperlipidemia, hypertension
look for cocaine-associated myocardial ischemia
* abcs - assess airway, breathing and circulation. patients experiencing chest pain may be having an episode of stable angina, usa or an acute mi, be prepared for evolution of the situation
cardiac decompensation - vital signs, skin color, temp, jvd, edema, s3 or s4
* place patient on oxygen - does the patient require more than nasal cannula? do we need an abg? lactic acid? requiring high o2?
* obtain 12 lead ecg stat
* resuscitation equipment nearby - allows for early and rapid treatment of decompensation and/or lethal rhythms
call rapid response team - if your organization has a team available
* cardiac monitor - place on patient. don't remove patient from telemetry monitor when placing on defibrillator, maintain both monitoring systems
* iv access - maintain at least one iv site, #20 gauge or large and obtain labs
draw cardiac enzymes (myoglobin, troponin, cpk-mb) and electrolytes to evaluate cardiac status and send to lab stat. if the patient is on digoxin (medications) may check level
* aspirin, unless contraindicated (allergy) - then the physician may order clopidogrel
* nitrates and morphine - unless contraindicated
sublingual nitro followed by iv nitroglycerine (ntg) for immediate relief of ischemia, coronary vasodilator, decreases preload
* check policy in your organization regarding ntg iv tubing
morphine acts as vasodilator and blocks the physiological response to pain
****notify the physician - of the patient status including symptoms, vital signs, i & o, labs and interventions. unable to read 12 lead and can't send it to the physician (fax, scan) tell the md what you see in each lead being specific. if available, call your organization's rapid response team for assistance. obtain orders for care provided.
* keep the patient on bedrest, monitor vital signs every 5 - 15 minutes during active chest pain and while on vasoactive drips, while awaiting further orders
* prepare patient/significant other(s) for revascularization - fibrinolytics, ptca, cabg
remember to follow your organizational policies and standards of care in dealing with a floor patient suddenly develops chest pain, prep for revascularization. (when in doubt remember "mona" - morphine, oxygen, nitro and aspirin).
.....any corrections accepted......