Chest Pain

Chest Pain

Clinical Findings

Neuro: Anxiety, restlessness, dizziness, lightheadedness, syncope; Pt may have sense of impending doom. Resp: Shortness of breath, tachypnea, abnormal lung sounds. CV:Tachycardia or bradycardia, signs of congestive heart failure. Skin: Coolness, pallor, cyanosis, diaphoresis. MS: Substernal pain, weakness, fatigue, sensation of chest heaviness or chest tightness. GI/GU: Nausea and vomiting.

Nursing Interventions

■ Place Pt in position of comfort and offer reassurance. ■ Administer supplemental oxygen titrated to SpO2 >90%. ■ Assess apical pulse for rate and rhythm. If Pt is monitored, assess ECG and manage dysrhythmias per ACLS protocol. ■ Obtain and document baseline VS (HR, RR, BP, temp, SpO2). ■ Obtain focused symptom analysis (PQRST). ■ Administer STAT medication if ordered: nitroglycerin 0.4 mg SL every 5 minutes until CP relieved (hold for BP <90 mm Hg); chewable aspirin 325 mg (non–enteric coated); morphine 2–4 mg IV (hold for SBP <90). ■ Notify physician of change in Pt status including pertinent assessment findings and interventions, if any implemented. ■ Consult physician about continued treatment, including ordering a STAT 12-lead ECG, labs (cardiac-specific markers, CBC, electrolytes, and coagulation studies), chest x-ray, and/or transfer to a CCU. ■ Document assessments, any interventions, and outcome.