CHEST PAIN - Nursing Assessment Guideline

Whenever a resident complains of chest pain ("uncomfortable sensation, tightness, strangling, squeezing, heaviness, indigestion, nausea"), concentrated behind the sternum or on the left side, with or without radiation, the following evaluation should be completed before calling the provider on call.

History:

1. What are the complaints? (specific words, location, severity)

2. Are there other signs or symptoms? (lightheaded, dizzy, nausea, palpitations, indigestion, breathless)

3. What was the resident doing when it started?

4. What is the contributing medical history? (Angina, CAD, MI, GI problem, respiratory illness, HTN, chest wall syndrome, anxiety)?

5. Are there other new status changes? (confusion, lethargy, agitation, slumping, flaccid limb, drooling)

6. What cardiac meds are ordered? Any recent med changes? Is the resident on Coumadin and/or Aspirin?

Physical:

7. What are the vital signs? (apical pulse, any new rhythm change)

8. If diabetic, what is the Accucheck reading?

9. What is the color & temperature of the skin? (dry, warm, cool, clammy, diaphoretic, pale)

10. Are there new abnormal lung sounds? (wheezes, rales/crackles, rhonci)

11. Is the abdomen tender on palpation? Bowel sounds? Last BM? DO NOT check for impaction!

12. Any increase in edema (periorbital, hands, lower extremities)?

Response:

A. For known cardiac condition implement PRN Nitroglycerin order, 

Put to bed; apply oxygen at 2L via NC.

B. If new onset chest pain put to bed, apply oxygen at 2L via NC and place emergency call.

NOTIFICATION CATEGORIES:

Emergency: New onset or recurrence not relieved by NTG X 3. Significant change in vital signs or Accucheck > 350

Routine: Relieved by NTG but status and/or vital signs not back to baseline. Increased use of PRN Nitroglycerine in short interval

If a resident does not have a DNR order - any chest pain, unrelieved by Nitroglycerine, should be reported as an emergency.

Revised 2/04