I had my first patient in active chest pain during my shift!

[christvs, DNP, RN, NP]

I've been an RN for 7 months now & I work on a med/surg/tele unit. I've had plenty of patients come in because they had chest pain at home so they got to the ER via ambulance, but I've never ever had anyone with active CP during my actual shift. So I admitted this man around 6 PM last night and he said he didn't have any CP but just "very slight" pressure in his chest, "not too bad at all" and didn't want or think it was even bad enough to need meds for it. He also had some leg pain so I gave him a tylenol and I just checked on him every half hour or so. I kept asking if he had CP every time I went in to see him but he said he was fine. So I showed him his call light and said he should press it if he felt CP or anything else abnormal. Then I went and took my supper break at 8:15 PM. At 8:30 PM I get called & of course I didn't know what for at this point, so I came out of the break room and the charge nurse is in the hallway getting the EKG machine out and said Mr "Smith" is having chest pain right now. So I tried to stay calm and ran into the room, the LPN I was working with did the EKG while I put O2 on him at 2 Liters and put the head of his bed up and grabbed his med sheets and checked his vital signs. His BP was 99/59 and he was rating his CP as 7/10 and said his collarbone also hurt, but denied SOB, nausea, dizziness, or any other pain. So I gave him one nitro under his tongue (our perimeters said it was ok to give nitro if SBP is over 90). And then I stayed with him and re-checked his BP (and everything else!) five min later and it was now 90/49, so I knew not to give him another nitro, but he was still rating his pain as 7/10, pule ox was 96 % on 2 L, HR stayed in the high 60s, tele was still NSR. So I called his docs with all this info, and said I gave him a nitro, his BP is lower now, so I didn't give a second nitro but he still has 7/10 CP, we did an EKG-want to come look at it and do you want me to give him IV morphine? So they had me give him 2 mg IV morphine and they came right up, looked at his EKG and said there were no changes so I could just resume his normal treatments! UMM...HELLO! He was still having 7/10 CP! What about that?! So then I gave his first dose of morphine, and kept rechecking him like every two seconds-his vitals were stable except now the BP dropped to 88/53. So I called the docs again-who left, so a covering doc was now on-I told him all this and how his BP keeps dropping and he still has CP even though the other docs said he was fine. So HE came up and saw the patient and said I could give him another dose of 2 mg IV morphine, which I did-and I asked him that I should obviously hold his PM dose of Lopressor, right? He said fine. So then after the second dose of morphine (and he got scheduled ativan and oxycontin) he said his CP was now 5/10 and his BP was 100/59, so I hunted down the doc and told him this, and so the doc told me, "I just saw him again, he is fine, don't worry. His BP was probably low from the nitro. Just re-check his BP and if he needs more morphine he can get it every 2 hrs." But the part that gets me is that I was worrying, because it was scary. Why should I NOT worry? I don't want him to have a heart attack. They (the docs) were saying they didn't think the problem was cardiac. The phlebotemist came up to draw labs too and I think his trops were flat, but still...I felt like I should be worried and that is why I kept checking him all the time. I charted all of this of course, I took up a whole page in his chart! :) I was happy with myself that I knew what to do without anyone telling me (about giving him O2, elevating the head of his bed, checking BP before and after nitro, checking all VS constantly, re-assessing the pt, calling the docs with all this) since this was my first CP experience. But I don't know why the docs weren't more nervous like me! They must be used to this type of thing! And I had one other patient, another was being discharged, and a brand new admission all at the same time! Phew! What a night. And today is my birthday-I'm 29 years old today. :) Eeek...almost 30! :)Thanks for listening if you are still reading this.

'-Christine

[SouthernLPN2RN, MSN, RN, APRN, NP]

Well Happy Birthday and congratulations for the successful management of an unstable patient!

[Altra, BSN, RN]

Happy Birthday Christine from another new nurse. (But I'm on the *other* side of 30 ... :chuckle )

[Adam D. RN2005]

Christine,

First, Happy Birthday. Second, good job. You did all of the right things. Sometimes you need to keep on top of what is going on. Chest pain can be anything. And there is such a thing as a silent MI, you have one symptom, and all of the others are missing. But again, good job, and again, Happy Birthday.

Adam, RN

[perfectbluebuildings, BSN, RN]

That is a stressful situation!!! It sounds to me like you did everything that needed to be done, keeping a very close eye on him, keeping MDs aware and asking them for new orders constantly as needed, and helped him with his pain. Did they ever think it could be something pulmonary? Oh I guess his sats were good, so probably wasn't that, just thinking of different causes for CP. Did they get any more definitive answers on it later on?

And, happy birthday!!!! :) WOO-HOO!!!

[Indy, LPN, LVN]

Don't EKG changes show up even on a silent MI though? When you have the patients with CP episodes, also remember, color, temperature, sweating? You'll see if their color is off, put a hand to their forehead or cheek, are they clammy and sweaty? Again, they don't all have all the symptoms.

When a perfectly pink, dry, warm person tells me their pain is so high, and not relieved, I just go with what I have ordered. Nitro, 3 times q 5 min, with blood pressures before each, unless it drops the blood pressure. Now if it drops significantly they can turn grey and sweat, and feel faint. It'll make the patient think they are really in bad shape too, so it doesn't help their anxiety one bit. If nitro doesn't work, is morphine or some other pain reliever ordered? Give it... see what happens, keep on top of vital signs.

Something I do NOT do is explain every single thing I'm thinking, because if you have a manipulative or psych patient they just jump on this info and keep you running all night long for no reason. Do explain the meds a little bit, so they know you're doing all you can. Check the chart... history of drug abuse? Too many or no narcotics ordered? Hmm. If none, and you see history of opiate abuse, just explain to the patient that you've done what you can and try to get the environment quiet for them so they can relax.

Also check lung sounds and what procedures they had done recently? Pleuritic pain can be a real bear to handle especially if they also have a cardiac history. Ooh, and if they had a pacemaker placed very recently (like in the last 24 hours or so) check for neck vein distension with head of bed at about 30 degrees. Lead wire screws can poke through the heart wall and have a little slow tamponade. NOT fun.

Don't forget Maalox, Reglan, Zofran, and Phenergan, if they are ordered and nothing else works... try one and see...

At any point in this process I may do an EKG... depends on if it's ordered before nitro or not mentioned. But it can't hurt to have something to compare with. If I've done all this and have no more PRN's to hand out, I'll call the doc.

I always pay close attention to the mannerisms of the patient and if I have family members freaking out I may try to get them to a waiting room so I can assess just the patient. I try to get the patient to use the pain scale, and there are some who just won't. I pay attention to the way they ask for what they want, etc. The person who turns gray and says, "don't leave me" while breaking into a cold sweat gets what she asks for, and I get some help, even if it's just the nitro that did that... The pink, bright-eyed, perky lady who won't use a pain scale and swears that "oh, I'm just about to check out of here" might, in the end, wind up with maalox, milk and a sleeping pill, maybe some hand-holding and TLC.

I'm rambling; I hope that helps. They're all so different... There's little to no doubt if the person is really crashing; the trick is trying to catch those atypical ones before they get to that point.

[Indy, LPN, LVN]

And by the way, the docs weren't as nervous for many different reasons. They may have been busy, didn't think he had significant blockages, or knew his history, etc. If they get worried you'll know.

You did a GREAT job with your patient though! One thing that helps with charting is the scribble pad- jot down what time you do things with your real quick shorthand and keep in pocket. When you go to chart, it'll come in handy, you'll have your exact timeframe down and you can just chart away. Also helps if other nurses or the doc are asking questions before you got a chance to chart. I make a point to not use napkins for that stuff 'cause I will inevitably blow my nose on it and throw it all away!