Chest Pain in LTC

WHERE I WORK.......IF THE RESIDENT HAS A STANDING ORDER FOR NITRO ...I FOLLOW THAT ORDER...IT NO RELIEF AFTER THE 3RD NITRO......I WILL THEN SEND OUT TO THE E.R. THEN NOTIFY THE DOC.......IF PT HAS NO STANDING ORDER FOR NITRO.....I SEND THEM OUT RIGHT AWAY....THEN NOTIFY THE DOC....I WOULD RATHER BE SAFE THAN SORRY..........LAST PT I SENT OUT THAT COMPLAINED OF CHEST PAINS...HAD NO STANDING ORDER...SO I SENT HIM OUT....NOTIFYIED M.D. AFTER.....(WHICH HE YELLED AT ME FOR, FOR NOT NOTIFYING HIM 1ST) AND THE PT WAS ADMITTED TO R/O MI...WHICH HE TURNED OUT TO BE + FOR LATER........SO ONCE AGAIN BETTER SAFE THEN SORRY.

Yep me too on sending them out. First I'll assess them and make sure its not gas or SOB or something else. Do a set of vitals, nitro if they have an order, Baby Asa, and slap the O2 on them in the mean time. In emergencies I always call family, send first then call the Doc later, Im not waiting 1/2 hr plus for the doc to call back. In LTC, though, it's important to always check the advanced directives first.

Cardiac nurse's imput...

Determine PQRST of pain, make sure you have a B/P prior to administration of NTG if they have an order. Make sure that they are lying down, not in a chair, wheelchair,etc no matter how much they complain. It is a whole lot easier to treat hypotension with a person in bed then in a chair. Oxygen is good too. Reassurance that they are going to be treated and watched. This is good for the anxious types. Remember that chest pain symptoms can vary from person to person. I have found that women and diabetics have had MI's with strange symptoms that were ignored.

This is coming from an ER nurse, even though i am new this is what i think.

Start of course with MONA, if you have an order. Morphine, Oxygen, Nitro, and ASA. If you don't have an order don't do it. That is one way it is different from the er. While you are getting all this established have the unit clerk if you have one, page the MD for you, so that is being done while you are using up time assessing and treating the patinet.

If you have time and your gut is telling you this is possibly a true MI, maybe get another line, large bore, if the other line is troublesome or not very big.

Remember you can always put 02 on and later take it off.

If your gut tells you they are in trouble get them out, where they can be put on a monitored bed.

MONITOR what you can while on the unit. ie. SPO2, pulse, b/p etc. These can give you the information when they are starting to go down hill. You just won't know if they are having an MI.

If you have an ECG tec. or ECG capabilities on the floor get an ECG as well!

Hope this helps you a lot!

When I have a resident c/o chest pain, while taking his vitals I ask him, "what kind of pain is it and what number (?/10), does he have any tingling, numbness in his arms, nausea, dizziness" Observe his color, any diaphoresis, cold and clammy, observe respirations, dyspneic? are they even unlabored, moist sounding? is his pulse rate bounding, thready, or irregular, while observing his LOC, have someone stay with the pt, administer O2 @ 2L until further orders, give him Nitro if he has an order, if not, notify the doc on call, give him pt's name, age and Dx, explain the problem, give him the VS, POx. Our Docs will ask if he/she is DNR, DNI, DNH, any advance directives. I'll Have that info available for him also. I work nights, and have no unit clerk ...I wish! Then return to the resident. Have someone available to direct the doc to resident's room if I don't see him first. Oh, and do an EKG and have the crash cart outside the room.

In my past experience, we ruled out crdiac issues as described above then treated for gas.

Some patients respond to a dose of Maalox, but some O2 in the meantime won't hurt, and you will be waiting for the doc to call back anyway. Of course if you know it's cardiac, or if they look sick, or if you feel skittish about them...go for the gusto.

Check their advance directive before you start sending them out, their (or their family's) wishes may be to be kept comfortable.

Originally posted by night owl

[bare they even unlabored, moist sounding? is his pulse rate bounding, thready, or irregular, [/b]

And then what do you do with this info, just tell the doc? I mean, moist sounding breath sounds seem like CHF and irregular heart beat could mean cardiac dysrhythmia that will lead to Vfib. What about bounding?

At the LTC I used to work @ it was Full set of VS o2 on @ 2 liters nitro x1 repeat BP repeat nitro followed by BP and a 3rd nitro If no improvement send out but where I worked we were not allowed to send out without MD order fortunately we were always put right through with the on call MD. I had to do this with a 100yr old DNR but she was A&O and asked to go to hospital. It was CHF and she lived another 3 yrs dressing and feeding herself to the end. I loved that ladies spunk.