Standing orders for chest pain

Indy, LPN, LVN · Jun 2, 2006

What I meant is that ACLS is based on some literature, somewhere, most of which I don't have. But the recommendations for ischemic CP or unstable angina come from somewhere. That'd be a good start if looking for literature to support some type of protocol.

If your hospital expects you to take care of patients with angina, like Timothy said, they need to have orders for it. I'm a bit spoiled as even the hospitalists don't admit patients to our unit for angina unless the O2, NTG, morphine, ekg, ASA orders are in place. If they did I might be 15 minutes into treating CP before calling the doc for orders, and so to avoid that situation of the nurse calling for orders on what we already did, they seem to have some sense and just do the orders right to begin with.

If you're seeing a lot of patients with CP and without sensible orders, I'd say start documenting it and go up the chain of command with some statistics.

Sylv · Jun 25, 2006

What's the cutoff point for the BP where you wouldn't give nitro? How low? What would they do instead for pain? Morphine will also lower the BP, right? What if the BP is low to start, but okay to give the nitro, then after 3 doses the BP goes to like 80/40 or something what do they usually do then for the low BP?

Just trying to learn here.

pickledpepperRN · Jun 25, 2006

Our admitting orders page (both computer and hard copy) has chest pain protocol stating beside a small box, "Unless checked implement chest pain protocol per RN assessmtnt.

It includes:

oO2 2-4L/m per nasal cannula

oNitroglycerine 0.4mg SL stat x 1

o12-lead ECG stat

oIV fluids 250cc NS at TKO

If ST elevation is present on the 12 lead we may give NTG twice more. Before that we have the cardiologist on the phone. We can always call a resident too.

Indy, LPN, LVN · Jul 11, 2006

For nitro the blood pressure cutoff depends on the patient. I take BP before giving it, each time. So if the first nitro after 5 minutes drops the systolic 20 points ... and it's NOT a post pacemaker insertion patient... (will explain in a bit) and the patient is not relieved of pain, and the systolic now is say, 130's... then I might give another nitro.

Some people drop a lot then not at all. Some people drop so much with the first one that they're not eligible for another. Usually if the systolic is around 100 I stop. Or if they're normally 100's stystolic I might give one but I don't have the intention of giving three of them, especially if they start out low. I would like the SBP to stay over 90.

Post pacemaker insertion, that is, not a battery replacement but the actual leads, is a little different. Sometimes the little screw can poke through the ventricle wall and cause a little chest pain, and/or a little tamponade. Nitro can make the patient (any patient really) more symptomatic with a good drop in BP, can cause diaphoresis, cold clamminess, etc. So can tamponade, so with a post pacemaker insertion, I'd shy away from nitro in order to see more "real" symptoms and less symptoms caused by nitro.

The last paragraph is advice from a real incident where the cardiologist who inserted the pacemaker gave me direction, for future patients. Yes, the standard CP orders were in effect on the patient, but since I was so worried about her, he explained a bit. With tamponade, if it's slow, the patient will just not be able to get comfortable. They'll whine, and be really vague with their symptoms, before they crash.

Did that help any? Sorry for the rambling.

Indy, LPN, LVN · Jul 11, 2006

Sorry. I'm silly and can't figure out how to edit tonight.

I didn't answer your other question. I haven't seen morphine drop BP as quickly or as drastically as nitro can but that's because I'm slow with morphine for chest pain. One milligram per minute, reevaluate. If the patient simply can't keep a systolic over 90 then they're going to get a fluid bolus, I'm gonna call the doc, they're probably going to ICU where, depending on if they are still in pain, they'll get some combination of NTG drip (if pain unrelieved), dopamine maybe, fluids, etc.

Hope that helps!

Sylv · Jul 12, 2006

Thank you Indy, that did help!

rninme · Jul 18, 2006

I just got back from a cardiac drug conference....and they are cautioning the routine use of NTG in rx'ing chest pain.

"Just say no to nitro"!!!! without first establishing an IV; r/o a RVMI or hx of aortic stenosis; and r/o pt's use of ....let's call them "enhanced-performance drugs"....especially cialis.....which has a 72 hour "performance window".

Interesting....don't know if it will become a standard of care or not.

zookeeper · Jul 18, 2006

I had a pt, say 5 yrs ago maybe, that I was giving his ordered nitropaste to. (It was just after we had had an inservice mentioning nitro in an RV MI and the result if you do) It wasn't 5 minutes later the wife came out of the room a little nervous---said something wasn't right. This guy was gray and BP was 60. All I remembered from the inservice was GIVE FLUIDS in a Right-sided MI. So I ran for the fluids while someone else called a code. We hung the fluids, respiratory ended up having to intubate, but he died in the code despite our efforts. Profiles; hot of the press -positive. (we weren't doing Troponins back then). Yeah, I definitely wanna know what type of MI if I can.

By the way, thanks, Indy, for the tip about "post pacer" CP I've never heard that.

Indy, LPN, LVN · Jul 23, 2006

Oh, and btw, you're right about the thing with aortic stenosis. We've had a few people with that, severe enough that the doc said "NO NITRO." If I see that in the history and physical, but not written as an order, I'll put it on the computer as a nitro allergy so pharmacy will see it, and pass it off in report. It would probably be a good idea to put a sign over the bed that said "no nitro" - kind of like how we do signs for "no bp or sticks in -- arm" for post mastectomy/ AV shut patients.

And I do ask my male patients about viagra type drugs. I explain that I don't care if they use them, but some people are too embarrassed to admit to them on admission, and I don't want to harm them by giving them nitro if they do use them. They mostly all blush over that little speech.

RegisteredNurse06 · Aug 19, 2006

Does anyone have standing orders or a practice guidline for pts with chest pain at thier facility?
It seems to me that pts get faster care for chest pain if they out in the community than if they are already in the hosp. If 911 is called they get O2, S/L Nitro, aspirin and an EKG as soon as the EMTs arrive. In the hosp they have to wait until the MD calls back and the nurse gets orders.
Please let me know what the procedure is at your facility and what literature supports your practice.

Our facility has telemetry protocol orders. Anyone admitted to our unit automatically has PRN orders for SL NTG, tylenol, O2 @2-4L/NC, EKG, and some other goofy stuff like MOM, Mylanta & a couple other things. What we don't have is orders for obtaining cardiac enzymes and for giving morphine. I HATE that. I called a doc this morning about a patient who was having CP and he gave me the order for morphine but didn't give an order for cardiac enzymes. That bothers me.

lmessajumper · Aug 22, 2006

Here is the "Chest Pain Protocol" from the hospital I am on assignment on. These are automatically done on our MS/Tele unit on every patient - unless otherwise ordered.

1. O2 @ 2-4l NC

2. Record O2 saturation

3. Obtain STAT 12 lead EKG prior to NTG.

4. Give NTG 0.4mg SL every 3-5 min x 2 for SBP >90 or _______ mm Hg. If SBP

5. If no relief with NTG, give Morphine 2-5mg IVP and notify physician immediately.

6. Mount EKG strips with chest pain onset.

These are good for nurses that do not always work tele. This is a small 10 bed unit.

rehabrn11 · Aug 28, 2006

Yes we have standing orders for patients with chest pain that come from ER or the floor.