Chest Pain in ES

[anxiousnewgrad58]

What do you all do for your elementary school kiddos complaining of chest pain?

I am brand new to school nursing and subbing a few weeks at a school I am not familiar with. A kiddo came in complaining of chest pain "like someone punched him in the chest" as I was about to walk out of the door for the day. I asked when it started he said 10 minutes ago in math class. He had no n/v, SOB, headache, dizziness, difficulty breathing. He was talking up a storm with no difficulty let me know he had a bit of a sore throat and hurt his wrist at recess. Told me about every bump and bruise he's ever had. Looked completely fine no change in color, and no signs of distress. He wasn't crying or guarding his chest in the slightest. The front office staff let me know he is seen frequently and they thought he was just fine. Another nurse in the building also was ready to send him right back to class. 

I struggle with school nursing as I always feel like this may be the one child where something is gravely wrong. The schools in my district have essentially nothing in the building (no pulse ox etc). I had him rest in the office and drink water which made him feel "a little better." Before going back to class I said he could stay for a few more minutes but he wanted to go back (he was very bored in the office with us). Although everyone else was ready to send him back to class I called the parent especially because he has a hx. of asthma that he "mostly grew out of" he also takes ADHD medications.

I told the parent he seemed to be in no immediate distress. I asked about his asthma. I gave the parent the option of what to do but said I could send him back to class for now after resting and hydrating with instructions to return to the office with any complaint. Parent was comfortable with that. I instructed the parent I always strongly recommend contacting ped for anything "chest and above." I checked in with parent once the kiddo was home from school.  Kid explained to parent something a bit different from me and said it was "tightness" parent thought he may have gotten a little tight at recess and kiddo said "maybe that was it". He was already asking to go outside and play and acting his normal self per parent. 

I know that with peds chest pain is rarely cardiac. It could have been GERD from lunch (taco day), mild asthma symptoms from recess during allergy season, the very beginning of a mild viral infection, anxiety or distress over his wrist injury (from baseball at recess), MATH CLASS itself or a million other things. I just feel like I under reacted here partially because of the opinion of the health aid and other nurse there. If I would have been solo I would have done further investigation, taken a really good listen (although my ped assessment skills are not stellar I.e. I can often find some issue when nothing is there). I felt a lot of pressure to not over react (as I tend to do because I am new to nursing in a well population) and feel like I failed this kiddo by undereacting. I am having a hard time letting go of this one. What would you have all done and do you think I messed this one up? I will take any honest critique at all. 

[NutmeggeRN, BSN]

You did just fine. Remember you ABC's...color good, VS good, no acute distress....you made an assessment and the appropriate follow up. Well done!

[JenTheSchoolRN, BSN, RN]

You did just fine.

One thing I have learned about school nursing: we look for horses first, rather than zebras. Because 9.5/10, it's a horse, not a zebra.

[Flare, ASN, BSN]

Generally, it's the anxious kids who come in with "my heart hurts"  or "my chest hurts" full set of vitals either way and a little interview as to what was happening right before.  A little rest and as long as everything looks OK, back to class.  I will usually call the parent at least the first time to see if this is a concern at home, history of asthma, etc.  If it becomes a pattern, that warrants a call, too.  A kiddo that feels the need to tell you their entire medical history including all the bumps and bruises he's ever had is probably either a bit anxious, attention seeking, avoiding work, or a combination.  It sounds like you did not under react, sounds like you did fine.   

[yaRNthrower, BSN, RN]

You did a great job. You will get more comfortable everyday. You hang in there and welcome to school nursing.

[NurseInTheHall, ADN, RN]

Agree with all above - you did great. You are at a disadvantage being the sub or new to the school. It's easier when you know the kids. 

I love to employ the 'boredom therapy' method.  After an initial assessment, a small drink of water, and allowing them rest (sitting, not laying down/napping), I then go about something administrative on my computer. It doesn't take them long to decide they are ready to return to class. If something really is wrong, you'll know that pretty quickly, too.

[Wishinonastar, BSN]

I will tell you one thing, ADHD meds can cause chest pain, and racing hearts and severe headaches. I know so many kids need these meds to get through school but I have seen many kids on ADHD meds with chest pain. Not sure if it is a result of the effects on the heart, or the anxiety that can also come with these meds AND with ADHD. Assessing kids can be tough. You are right, it is the one time you assume it is nothing that it turns out to be something. 

What I have learned is to use my assessment skills- kids can dramatize sometimes, but if what you see, hear and observe does not fit with what they are saying, you go with what you assess. Listen to the heart and lungs, look at their respiratory pattern, look at their lips and nailbeds. In general, you can tell if a child is truly sick. And if you do an assessment, you have covered yourself in case you are wrong. If in doubt, you can call a parent to ask if this has happened before.

I had a student once complaining of menstrual cramps. I let her lay down, did not think much of it. She told me it was menstrual cramps. Later after school she ended up at the ER with an appendicitis. Thank goodness I documented what she said- how many nurses check for rebound tenderness with menstrual cramps? We assume a girl knows when she has them. This time, she was wrong. She was not writhing in pain. It was not severe. Just cramps. Only it wasn't. Lesson learned. My ears perk up at cramps now. 

Sounds like you covered your bases with this child.

 

 

[JenTheSchoolRN, BSN, RN]

17 hours ago, nursemarion said:

 

I had a student once complaining of menstrual cramps. I let her lay down, did not think much of it. She told me it was menstrual cramps. Later after school she ended up at the ER with an appendicitis. Thank goodness I documented what she said- how many nurses check for rebound tenderness with menstrual cramps? We assume a girl knows when she has them. This time, she was wrong. She was not writhing in pain. It was not severe. Just cramps. Only it wasn't. Lesson learned. My ears perk up at cramps now. 

Sounds like you covered your bases with this child.

 

 

Appendicitis in kids is not always textbook either. I've had two kids (1 this year, 1 a couple of years ago) that did not have rebound tenderness - both complained of general belly pain near the umbilicus that could have easily been indigestion related. No temp, no other symptoms. But neither of the kids were complainers and something just felt "off" to me with them.

I called the parents of both, sent them home, and advised monitoring and follow-up. Both ended up at the ER that evening and in surgery the next day. Both sets of parents were so grateful that I "knew" their kid enough to realize something was up.

But this "gut" feeling is something you develop with time and practice as a school nurse. But I never ignore it when I get that feeling. 

It is okay when it feels like we "over" assess as well, especially when the student is new to us. When we get a chance to know them, we then get a chance to learn their nuances ;).