Help me! What do you look for if a patient says

pagandeva2000, LPN · Aug 16, 2007

"I'm having chest pain" and you work the night shift at a LTC facility!??!!
I'm new, still have MANY things to learn.
If a patient says this you have him sit down or elevate the bed, ask him about the pain (intensity, location, when it began and what makes it worse), take vitals, search for nitro or aspirin then do what??????? Do you wait to see if the chest pain goes away with nitro or aspirin? Do you go ahead and call the doc anyway? Do you send him out?
What if someone is vomiting and has no order for any anti-nausea meds? Vitals, again question them when it started ect.. do you call the doc or wait until morning if it's "normal" looking?

I'd make sure that there is an order for nitroglycerin or aspirin before administering it, and would definitely call the RN and physician for further direction. I am a new nurse, only been one for a year, so, I understand your fear. One of the things I would do is see if there are standing orders for such things, and make sure that you know how to call or page the RN. Ask them for their protocol immediately, and do not be embarassed to say that you don't know. It is better to seek clarity than to risk someone's life. Also, I would administer 2 liters of oxygen as he is sitting while taking his vital signs. I am interested to hear the other responses because I am learning, too!

Fiona59 · Aug 17, 2007

What kind of pain?

Does it travel up your arm, neck, face?

Full set of vitals (including O2 sat level)

What was the last thing they ate (a lot of chest pain can be heart burn)

Check the prn meds. If you decide to use the nitro, monitor every five minutes and watch for a headache (the patients not yours)

If the nitro doesn't work after three applications, call your RN or Dr.

You have to know your patients before administering O2. If they are CO2 retainers, you usually want to keep them below 90%.

TheCommuter, BSN, RN · Aug 17, 2007

Unfortunately, there's typically no RN in the building during the night shift in most LTC facilities. Therefore, the buck stops with the LVN/LPN in this situation. Also, female patients present differently. Their back might be aching, but they are really having a heart attack.

I'd personally give 3 doses of NTG if it is ordered. If the NTG fails to alleviate the chest pain, I'd call the on-call physician to obtain a telephone order to send the patient out immediately. Some nurse managers at LTCs do not like patients being sent to the hospital, because the ambulance transport to the hospital costs the facility money. One of my nurse managers told me to give the patient Maalox to see if the chest pain was heartburn. I ignored her, and sent the patient out!

Fiona59 · Aug 17, 2007

The majority of LTC facilities up here have a "facility RN" or an on-call to call before tracking down a Dr.

steelcityrn, RN · Aug 17, 2007

If the patient is a full code and had nitro ordered,you would give as directed q5min x3, then if no relief you call 911. As for a patient with nausea only, that occurs late or in the wee hours with no prn orderd, I would offer gingerale and a few dry crackers if the patient is allowed to have these, or can tolorate. Either have oncoming obtain order for this if it occurs again, or call before you leave. Im from the don't call and wake a physician up if it can wait, they have a full day ahead of them once they do start working. And as for vomiting, if its you normal vomit, no blood or violent vomiting, that can wait also if once they empty it out and feel a little better. 911 if bloody or they become even worse .

rn/writer, RN · Aug 17, 2007

Remember to get serial v/s so you can spot a trend. Q 15 minutes. A competent CNA can do this while you do the other things. It could take an hour for the doc to call you back. You should have 4 or 5 sets of v/s by that time.

Keep the patient in a position of comfort. Most will want semi- or high-Fowlers.

Daytonite, BSN, RN · Aug 17, 2007

CrazyFLBean. . .many years ago when I was newly working on a medical unit that had telemetry I was faced with this same situation: What to do when a patient complained of chest pain? After the episode was over and I sat down to chart it I often found I had missed a few things. So, being the creative person I am, I sat down and worked up my own flow sheet that included the hospital policy and typed it up on a manual typewriter (this was in 1978) on a piece of yellow paper and then "laminated" it by covering it, front and back, with clear contact paper. I still have it and carried it for many years on my clipboard. I'm looking at it now. I pulled it out of my box of nursing stuff. I am typing it out for you here. Please feel free to copy, edit and use this information for yourself.

When I had a patient who complained of chest pain, I would pull this sheet to the front of my clipboard, grab a sheet of dry paper toweling (to write on), get a bottle of NTG, pull up a chair and sit at the patient's bedside for the next 15 minutes or so taking vital signs every 15 minutes, giving the NTG and collecting assessment information. If the pain wasn't getting any better after 3 NTG tablets and 15 minutes, the doctor was called and I had all the information I needed in front of me. NOTE: administration of NTG was in our standing orders for a patient having chest pain. You should have a physician's order before you give any NTG.

To be prepared about angina and atherosclerosis of the heart, the major cause of angina which also is a progressive pathway to an MI, read up on these conditions. In LTC you have to inform the patient's doctor of any change in the patient's condition. You will get into big time trouble with the DON and the state if you don't notify the doctor in a timely manner. If you have no orders to treat the patient's chest pain, then you do a set of vital signs and a quick assessment since time is of the essence, get on the horn (telephone) and notify the doctor who is on call for the patient's attending physician. The doctor most likely will want to try some NTG to see if it relieves the pain. If NTG doesn't work, then the doctor needs to be called back for more direction. Unrelieved chest pain could be a symptoms of an impending myocardial infarction (MI). If you have trouble reaching a doctor, call whoever is on call for your DON to get further advice on how to proceed/or call 911 if you think the patient might need transfer to the hospital. You cannot ignore chest pain and must do something proactive when it occurs even if it ultimately turns out to be nothing serious.

****************************

Nursing Actions During Angina

Note subjective symptoms of pain (patient statements) - location and type
- location of pain
  - Retrosternal - behind the middle or upper third of the sternum
  - Substernal - at the center of the chest
  - Radiation - to one or both arms, shoulders, back, neck, jaw or ears with increased intensity of pain or discomfort
  [*]types of pain (patient's description) - chart the words the patient uses
  - pressure
  - tightness
  - burning
  - choking
  - strangling
  - pressing
  - constriction
  - squeezing
  - heaviness
  - dull ache
  - indigestion
  - palpitations
  - a sense of fullness
  - a vice closing around the chest
  - someone standing on the chest
  - clenched fist syndrome (patient demonstrates this by clenching the fist and holding it over their chest)
  [*]associated objective symptoms (you observe)
  - apprehension
  - feeling of impending death
  - increased perspiration
  - increased heart rate
  - elevated blood pressure
  - headache
  - clenched fist syndrome (patient demonstrates this by clenching the fist and holding it over their chest)
  - paresthesias (numbness or heaviness) of arms, wrist, fingers, hands or around the mouth
  - pressing or rubbing on the sternum
  - complaining of not being able to breathe although dyspnea is not present
  - stopping all activity and remaining still
  - eagerness to take nitroglycerine (NTG)
  - belching
  - an S3 gallop during the angina
  - S2 split
  - S4 gallop
[*]
Objective information to collect
- onset of pain - what was the patient doing at the time of the attack
- vital signs - take B/P and pulse in both arms, check all pulses for asymmetry or absence, check for carotid bruit
- palpate the site of pain and note any tenderness
- note breathing and check lung sounds
- heart assessment - note any gallops, murmurs, pericardial rub, extra sounds
- skin assessment - note any pallor, ashen color, perspiration, coolness, clamminess, warm/dry, check nail beds and lips for pallor or cyanosis
- emotional state - anxiety, apprehension, restlessness
- neurological - LOC, pupil size and reaction, motor movements and coordination, sight, sound, smell taste
[*]Elevate the head of the bed
[*]
Give NTG, if ordered, one every 5 minutes up to 3 (this was in our standing orders)
[*]
EKG, if ordered
[*]
Oxygen, if ordered
[*]
Call MD if pain increases or changes within 15 minutes, or pain lasts more the 30 minutes (this was in our standing orders)
[*]
Record duration of the attack and how much NTG was taken
[*]
Determine if this is similar to patient's other anginal attacks (precipitating factor, intensity, radiation of pain, duration, mode of relief)

ABOUT NITROGLYCERIN

Take note of how long it takes for relief of the chest pain to occur after NTG is given
How many NTG tablets were taken
Side effects of NTG
- hypotension and faintness (take B/P every 5 minutes after given an NTG tablet)
- Drowsiness
- Dizziness or syncope
- Pounding headache or visual disturbances due to dilation of cerebral vessels

SYMPTOMS OF AN M.I.

For pain lasting more than 30 minutes without relief from NTG suspect an MI - intense crushing sensation or severe prolonged chest pain; knifelike, sharp, shooting, stabbing, or throbbing; radiation to face, head, scalp, abdomen, groin or knees; different from angina pain
Nausea and vomiting
Cool, clammy skin; profuse diaphoresis
- NOTE that the 3 P's of an MI are: Pain, Puking and Perspiration

[*]Pallor or ashen color

[*]

Dyspnea

[*]

Anxiety, apprehension, restlessness

[*]

Moving about in search of a comfortable position

[*]

Tachycardia or bradycardia

[*]

Sense of impending doom prior to onset of pain

nursn4me · Aug 17, 2007

Daytonite,

Thank you for the post. That is going to be so useful to me while in nursing school to use that critical thinking sheet. I can use that for studying and also for clinicals. :lol2:

MissChatLPN · Aug 18, 2007

I work LTC as well. In my facility, If a resident has chest pain we are instructed to immediately call the doctor after getting vitals and a description of pain from the resident. If the doctor does not call back (I work graveyard) then we send the resident out.

As far as giving meds for vomiting or anything else, i absolutely don't do so unless there is an order. Some docs get ticked when u call them in the middle of the night, but they soon get over it.

CrazyFLBean · Aug 18, 2007

My facility does not have a RN at night. Thanks for your help, I wish the people I work with could be as helpful as you all!!!!!!!!

I feel so useless sometimes and keep telling myself that one day I will know what to do :-/

UM Review RN, ASN, RN · Aug 18, 2007

These are all excellent things to do if the patient is having chest pain. On our unit, we have standing orders for vitals, O2 at 2L via nasal cannula, a 12-lead EKG, a 325 mg aspirin (if not contraindicated), 0.4 mg Nitro SL (if not contraindicated), and Maalox. After these things are done, whether or not the patient has had relief, we still have to call the doc to inform and possibly receive orders.

The most important rule in all of this is that we cannot know for sure until the labs and tests have all come back negative. So if you haven't the capability to do a chest Xray, Cardiac enzymes, a d-Dimer, a BNP, and things like that, don't assume that the person doesn't have something emergent going on.

Chest pain, especially in an elderly person, is something that needs to be checked out. Even if it sounds like classic indigestion, with epigastric pain, nausea and vomiting, it could be an MI (this is because the inferior wall of the heart is pretty close to the vagus nerve and an MI can stimulate the nerve, causing gastrointestinal disturbances - the classic "I have to have a BM" line).

Other patients only have shortness of breath and/or weakness with an MI. Women frequently feel back discomfort and weakness. Diabetics can have silent MIs.

Chest pain could be a PE, pneumonia, a collapsed lung, angina. Even a gallbladder attack will sometimes cause the ER doc to admit as a "Chest pain, rule out MI" or "Chest pain, low probability MI".

Some patients ask why is my heart being checked when I just felt a couple of pains, a little sick to my stomach and weak?

The reason is that the most vital organs need to be checked first. So if a person has chest pain, tests will be performed that will rule out a heart attack or pulmonary embolism or other potentially fatal diseases.

If it's not something like that, often the docs will then order a GI consult and anything abdominal will be ruled out.