"My chest hurts"

  1. What do y'all do to assess chest pain, and what do you tell the parent when you call them, in terms of follow-up?

    This is possibly the complaint that makes me the most crazy! It's so non specific and could be a thousand things, from the most benign to very serious.

    I ask questions to rule out asthma, heart burn, pain r/t coughing, being hit in the chest, any other PMH. I listen to heart, lungs, take vitals. I call the parent to let them know (if I can get them on the phone), but if all is WNL and the kid is still complaining of this nonspecific chest pain, I'm never quite sure what to recommend to the parent. Call Dr? Monitor at home? Send back to class and recheck later? Etc.

    I have worked hard to get teachers not to send kids for minor things, but of course saying "my chest hurts" (or "I can't breathe") will get them a trip to the nurse. I have 150 asthmatics, and I feel like their classmates see them getting sent to the nurse for these complaints and decide to try it too. Except, in their case, everything WNL

    At my school, I sometimes have a hard time getting parents on the phone, and I don't have physicals for a lot of kids, so I'm often working without the medical history I need. (But that's a separate post!)
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  2. 12 Comments

  3. by   ruby_jane
    [QUOTE=great_lakes_expat;9637118] I ask questions to rule out asthma, heart burn, pain r/t coughing, being hit in the chest, any other PMH. I listen to heart, lungs, take vitals. I call the parent to let them know (if I can get them on the phone), but if all is WNL and the kid is still complaining of this nonspecific chest pain, I'm never quite sure what to recommend to the parent. Call Dr? Monitor at home? Send back to class and recheck later? Etc.QUOTE]

    YES! That's what I do. If everything including anxiety can be ruled out, I will sometimes take the Littman and listen to heart rhythm and rate for a good long while. Most of the time it's nothing.

    As long as you're documenting everything, whether you can or can't get a parent is pretty much immaterial...if the kid needed to leave quickly, you'd call EMS. If the kid's got something simmering or it's anxiety, rest, hydration and it can all be handled by parent out of school hours.

    Most of my chest pain kids are anxious. There was one that I swear I was about to call EMS on until I actually reached dad - dad stated the kid had an accident where seatbelt deployed. Despite my asking "Is there anything else you can tell me," he chose to omit that fact....
  4. by   MrNurse(x2)
    Old cardiac nurse here. The first thing is to determine if it is worse with deep inspiration. Cardiac pain will not change with inspiration. This is hard for adults to discern, but be patient, they may be able to tell you. Most likely it is worse with respiration, that narrows it down to just about everything else. Next step would be lung auscultation, listening for rubs, crackles or rhonchi. Absence of those probably narrows it to muscular. True cardiac pain almost always is accompanied with anxiety, which is a real bummer, because anxiety can cause chest pain. Access to stock meds is your friend, because TUMS will quickly R/O reflux, NSAIDS for muscular pain. Always check pulse and BP for possible cardiac foci. Hope this helps.
  5. by   kidzcare
    Quote from MrNurse(x2)
    Old cardiac nurse here. The first thing is to determine if it is worse with deep inspiration. Cardiac pain will not change with inspiration. This is hard for adults to discern, but be patient, they may be able to tell you. Most likely it is worse with respiration, that narrows it down to just about everything else. Next step would be lung auscultation, listening for rubs, crackles or rhonchi. Absence of those probably narrows it to muscular. True cardiac pain almost always is accompanied with anxiety, which is a real bummer, because anxiety can cause chest pain. Access to stock meds is your friend, because TUMS will quickly R/O reflux, NSAIDS for muscular pain. Always check pulse and BP for possible cardiac foci. Hope this helps.
    Nice rundown!! thanks!
  6. by   OldDude
    On the elementary level I get quite a bit of "my heart hearts." Everyone knows it's a million to one against some cardiac issue but that still tumbles around in the back of my head. Good info Mr. Thanks!
  7. by   great_lakes_expat
    Quote from MrNurse(x2)
    Old cardiac nurse here. The first thing is to determine if it is worse with deep inspiration. Cardiac pain will not change with inspiration. This is hard for adults to discern, but be patient, they may be able to tell you. Most likely it is worse with respiration, that narrows it down to just about everything else. Next step would be lung auscultation, listening for rubs, crackles or rhonchi. Absence of those probably narrows it to muscular. True cardiac pain almost always is accompanied with anxiety, which is a real bummer, because anxiety can cause chest pain. Access to stock meds is your friend, because TUMS will quickly R/O reflux, NSAIDS for muscular pain. Always check pulse and BP for possible cardiac foci. Hope this helps.
    This is very helpful, thanks so much for sharing your experience! Especially about the changes with respiration. My kids are K-5, but I will definitely try it!

    Unfortunately, I don't have orders for Tums, just Tylenol or Motrin. I haven't tried either of those for "my chest hurts." I can see how that'd be great for the kids who are just having muscle pain. But would you give either of these if you haven't ruled out a cardiac issue?
    I know it's such a small possibility but it's always on my mind.
  8. by   great_lakes_expat
    Quote from ruby_jane

    Most of my chest pain kids are anxious.
    Yes! I often want to chalk it up to anxiety, especially with my "frequent flyers" who I know are always looking for reasons to get out of class, and anxiety plays a big role in that for a lot of them. But I'm never sure, and it's not like 3rd graders are so great at expressing emotions
  9. by   halohg
    All the above and I might also:
    For the non asthmatics:
    -depending on age: if the Little's I will ask them to point where on their chest or where is their heart pain. Many times they point to an area I would not consider their chest or heart.
    -I have a pulse oximeter and teach them what this assessment tells us, very reassuring and therapeutic for the student.
    -Along the same lines after I listen to breathe sounds and heart with a stethoscope and then allow the student to have a listen themselves again the student listening to their own heart is very therapeutic. I ask them or compare it to their classmate and confirm they both sound similar and the friend is okay so therefore so are they are in their mind.
    -Give a cup of water and discuss if anything else is going on: in the classroom, at home, sleep, diet, etc. distracting a bit, then ask them how are they feeling now. Nearly always with the Little's by this time, they feel better.
  10. by   JenTheSchoolRN
    Heartburn is becoming very, very common in the teens I work with. MrNurse gave an excellent run down (which I'm bookmarking - thank you!!!) to quickly rule out a serious issue. I am very lucky to have orders for Tums and ibuprofen, but if it is muscular, I have also used heating packs. Very helpful for the muscle strain from coughing.

    But flipside - I also have referred a few students to their doctors because despite exam ruling out an immediate serious issue, chest discomfort continues. (And student reports pain if I palpate the sternum and/or tell me pain increases with deep breath, yet lungs clear, HR regular and within normal range). Costochondritis was the diagnosis and they have come back to me with an order for 600 mg ibuprofen to treat the inflammation. It is actually fairly common in pre-teens, often with no known cause.
  11. by   NutmeggeRN
    If I cannot, after a thourough assessment, geta handle on things I call parent and ask them to call MD for followup. Obviously EMS if they are in any distress. Have had a variety of DX come back. Costochondritis, GERD, anxiety and pectis carinatum (pidgeon chest).
  12. by   Flare
    i get a lot of "my heart hurts" from the littles this time of year when they run around at recess and there just a bit too much of a bite in the air. A few cups of water, some rest time in the office and they are good as new. Of course I like to throw the pulse ox onto them anyhow - why not, right? I take a listen too - they are usually clear but every so often i hear a kid that has a wheeze and an undiagnosed or perhaps a long ignored asthma that benefits from having some albuterol in their lives. I will often call, but honestly, the kids that sit for literally 2 minutes, catch their breath and skip out are not a high priority for me to make a call.
  13. by   OyWithThePoodles
    I had one "chest pain" who upon auscultation had an irregular rhythm. I asked if there was any problems with his hear that he knew of "Nope." So I call home and they let me know that they just dropped of his 24 hour holter at the cardiologist for the same thing. No one bothered to tell the nurse. He had even wore the thing to school the day before. Very frustrating.
  14. by   BeckyESRN
    Quote from OyWithThePoodles
    I had one "chest pain" who upon auscultation had an irregular rhythm. I asked if there was any problems with his hear that he knew of "Nope." So I call home and they let me know that they just dropped of his 24 hour holter at the cardiologist for the same thing. No one bothered to tell the nurse. He had even wore the thing to school the day before. Very frustrating.
    C'Mon Now!

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