Rapid Assessment and Initial Actions
When a patient reports chest pain, a nurse's first response is to remain calm and initiate a rapid, systematic assessment. This immediate action is crucial for patient safety and outcome. The nurse must quickly gather information while simultaneously beginning interventions.
The "Look, Listen, Feel" Approach
- Look: Observe the patient for signs of distress, such as pallor, diaphoresis (sweating), or shortness of breath. Note their posture and overall appearance. Are they clutching their chest? Is there any visible cyanosis?
- Listen: Assess the patient's level of consciousness and listen to their verbal description of the pain. Ask open-ended questions to gather as much detail as possible. Have them describe the pain's quality (e.g., pressure, sharp, crushing), location, and radiation.
- Feel: Perform a quick physical assessment, including palpating their pulse and skin temperature. This provides a baseline understanding of their current cardiovascular status.
Initiating the Code and Summoning Help
Upon confirming the presence of chest pain, the nurse must immediately summon additional help. This might involve calling a "code blue" or using the facility's emergency response system, depending on the severity and patient's condition. The nurse must not leave the patient's side during this critical time. Enlisting a colleague to bring necessary equipment and notify the physician or Rapid Response Team is essential.
Nursing Interventions and Monitoring
With help on the way, the nurse's focus shifts to performing key interventions and continuous monitoring.
Vitals and Monitoring
Obtaining and recording a full set of vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, is a top priority. The nurse should immediately place the patient on a cardiac monitor to observe for any rhythm changes. A continuous pulse oximetry reading is also vital to track oxygen levels.
ABCs and Positioning
- Airway: Ensure the patient's airway is patent. If they are in distress, be prepared to assist with breathing.
- Breathing: Assess their breathing effort and administer supplemental oxygen as per standing orders or physician request, aiming for an oxygen saturation of at least 94%.
- Circulation: Ensure adequate circulation. If the patient is hypotensive, this will need to be addressed urgently. Placing an intravenous (IV) line for medication and fluid administration is standard practice.
Medication Administration
Following facility protocols and physician orders, a nurse may administer several medications to manage chest pain. These often include:
- Aspirin: Administering chewable aspirin (unless contraindicated) is a priority to inhibit platelet aggregation.
- Nitroglycerin: Often given sublingually to cause vasodilation and improve blood flow to the heart muscle. The nurse must closely monitor blood pressure as it can cause a significant drop.
- Morphine: May be used for pain relief if nitroglycerin is ineffective, as it also has mild vasodilatory effects.
Detailed Assessment: The PQRST and SOCRATES Mnemonic
Once initial steps are taken, a more detailed pain assessment is necessary. Two common mnemonics help organize the information systematically.
PQRST Mnemonic
- P (Provocation/Palliative): What makes the pain better or worse? Does it change with position or exertion?
- Q (Quality): What does the pain feel like? Is it sharp, dull, crushing, or a pressure?
- R (Region/Radiation): Where is the pain located? Does it radiate to the arm, jaw, back, or neck?
- S (Severity): Rate the pain on a scale of 0 to 10.
- T (Timing): When did the pain start? Is it constant or intermittent?
SOCRATES Mnemonic
- S (Site): Where is the pain?
- O (Onset): When did it start?
- C (Character): What is the pain like?
- R (Radiation): Does it spread anywhere?
- A (Associated symptoms): Are there other symptoms, like nausea, sweating, or shortness of breath?
- T (Time course): How has the pain changed over time?
- E (Exacerbating/Relieving factors): What makes it better or worse?
- S (Severity): How severe is the pain?
Comparison of Key Actions: Different Scenarios
| Action | Suspected Myocardial Infarction (MI) | Suspected Aortic Dissection | Non-Cardiac Chest Pain |
|---|---|---|---|
| Immediate Priority | MONA (Morphine, Oxygen, Nitroglycerin, Aspirin) | Blood Pressure Control | Assess and Rule Out Cardiac Causes |
| Medication Focus | Aspirin, Nitroglycerin, Morphine | IV Beta-Blockers | Analgesics if cardiac ruled out |
| Monitoring | ECG, Cardiac Enzymes | Blood Pressure in both arms, Imaging | General Vitals, Patient History |
| Key Intervention | Prepare for PCI (Percutaneous Coronary Intervention) | Prepare for Surgical Repair | Further diagnostic work-up |
| Patient Management | Calm, bed rest, reassure | Strict bed rest, avoid agitation | Position of comfort |
Providing Reassurance and Preparing for Next Steps
Throughout the process, the nurse plays a vital role in providing calm, reassuring care to the patient. Anxiety can exacerbate chest pain and other symptoms, so a calm demeanor is crucial. The nurse should explain each step of the process in a simple, straightforward manner.
As the medical team arrives, the nurse must provide a concise and clear SBAR (Situation, Background, Assessment, Recommendation) report to facilitate a seamless transition of care. The nurse will also assist with any further diagnostics, such as a 12-lead EKG, and prepare the patient for potential transfer to a higher level of care, such as the Intensive Care Unit (ICU) or Cardiac Catheterization Lab.
Conclusion
The nursing response to a patient with chest pain is a high-stakes, multi-faceted process that requires quick thinking, a systematic approach, and skilled interventions. By following established protocols, and maintaining a calm, reassuring presence, a nurse can effectively manage the initial phase of a cardiac event and set the stage for a positive patient outcome. Continuous training and adherence to evidence-based practice are essential for all nurses in emergency and inpatient settings. For further details on advanced cardiac life support, an authoritative source is the American Heart Association.
