Jamie Ranse

Registered Nurse

Emergency Department

The Canberra Hospital

Chest Pain:Nursing Assessment

and Management

Overview

• Causes of chest pain• Risk factors• Chain of Survival• Prioritising / Triage • Assessment• Nursing Management• Medical Management• Conclusion• Questions

Pneumothorax

Myocardial Infarction

Respiratory

InfectionAngina

Musculoskeletal

PericarditisAortic Dissection

Trauma

Anxiety

Pulmonary Embolism

Oesophageal Reflux / Spasm

Causes

Case 1:• 40 year old man• 2 hours central chest pain• Radiating to (L) arm• Pale, cold, clammy

Case 2:• 55 year old woman• 1 hour generalised weakness and unwell• Discomfort in throat

Who is having an MI?

Diabetes

High Blood Pressure

Physical

Inactivity

Over 40

Vascular Disease

High

Cholesterol

Previous MI

Obesity

SmokingFamily History

Unhealthy Dietary Habits

Risk Factors

• Early Recognition and Assessment

• Early Access

• Early CPR

• Early Defibrillation

• Early Advanced Cardiac Life Support

Chain of Survival

Case 1:• 40 year old man• 2 hours central chest pain• Radiating to (L) arm• Pale, cold, clammy

Triage:• Rapid Assessment• Prioritise Injury / Illness• Allocate Triage Category

Scenario

Primary Assessment• A – clear and open • B – spontaneous, AE R=L o added sounds • C – tachycardic - weak, diaphoretic• D – GCS 15, PEARL, full ROM / Strength / Sensation all limbs

Secondary Assessment• E – Change into patient gown• F – Observations: R: 28, P: 120, BP: 149/66, T: 372, (monitor) BSL: 6.9, Pain 5/10, SpO2 99% RA

• G – Comfort measures• H – Detailed history / Family History / heat-to-toe assessment

Time = Muscle

Assessment

lleregiesA

M

P

L

E

edications

revious medical, surgical and family history

ast meal

vents

Assessment

osition: Where is the Pain?P

Q

R

S

T

A

A

A

uality: What does the pain feel like? [sharp, dull, burning]

adiation: Does the pain move anywhere?

everity: Rate the pain on a scale between 0 and 10

iming: When did the pain start? Is it continuous?

lleviating factors: What makes it better?

ggravating factors: What makes it worse?

ssociated symptoms: e.g., nausea / pins and needles

Assessment

Inspect

Palpate

Percussion

Auscultation

Assessment

Ineffective cardiopulmonary tissue perfusion related to reduced coronary blood flow

Notify Nursing Team Leader and Senior Doctor

Primary• B – Supplementary Oxygen• C – ECG

Nursing Intervention

Nursing Intervention

Ineffective cardiopulmonary tissue perfusion related to reduced coronary blood flow

Notify Nursing Team Leader and Senior Doctor

Primary• B – Supplementary Oxygen• C – ECG IVC 18g Bloods to pathology (FBC, UEC, CP, CK, Troponin, ABG) Secondary• F – Observations • G – Analgesia / Medications• Reassurance, bed rest, patient and family education

Nursing Intervention

• Interpretation of ECG • Chest X-Ray• IVC bloods to pathology• Medications

• Anginine• Aspirin • Morphine• GTN infusion• Clopidogrel• Heparin• Cardiology Review

• Treatment Options• PTCA• Thrombolysis

Medical Intervention

Percutaneous Transluminal Coronary Angioplasty

• Examine coronary arteries• Dilate coronary arteries• “Gold standard”

PTCA

PTCA

• Unsuccessful stenting (<10%)• Inability to advance the wire • Re-closure • Vessel recoil

• Pain• Arrhythmia• Coronary spasm• Haemorrhage

PTCA: Complications

Indications for use • When PTCA unavailable• 25% - 40% to achieve normal blood flow

Complications• Major bleeding

Thrombolytics

• Causes of Chest Pain• Risk Factors• Chain of Survival• Assessment / Recognition Bias• Assessment• Nursing Interventions• Medical Management

• PTCA v Thrombolytics

Conclusion

Questions