Chest Pain (pressure, tightness)
Also Consider: Abdominal pain, Dyspnea, Nausea
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Causes
Common: Myocardial infarction / heart attack, rib / musculoskeletal pain, esophagitis
Less common: Pericarditis, aortic dissection, pneumonia, pulmonary embolus, pneumothorax, pancreatitis, gallstones, zoster / shingles, drug overdose or withdrawal
Caution: A patient having a heart attack can go into cardiac arrest. If the patient is “Full Code” move an AED to the patient’s bedside, if available, and be prepared to start CPR.
1. Take Vital Signs
Temperature:
Blood Pressure:
Heart Rate:
Respiratory Rate:
Oxygen Saturation:
2. Evaluate Symptoms and Signs
Chest pain: exact locations or radiation, pain scale, description (sharp, dull, burning), persistent or intermittent, worse with cough, breathing, palpation, or laying down
Fainting, dizziness or lightheadedness when standing up
Diaphoresis: Cold, clammy, pale skin
Respiratory: New cough, abnormal lung sounds, Accessory muscle breathing, pursed lip breathing, Respiratory distress
Cardiovascular: palpitations, new irregular pulse, cyanosis, mottling, edema
GI: Nausea, vomiting, indigestion, heartburn, epigastric tenderness, rebound tenderness, bowel sounds
Skin: rash on chest, side, or back; areas of tenderness
Response to any ordered PRN medications (nitroglycerin, antacid, oxygen) or repositioning
Fingerstick glucose (patients with diabetes)
3. Take Action using SBAR Report:
Immediately notify the medical staff & resident representative
New or unrelieved by current cardiac medications or returns shortly after treatment
Notify medical staff & resident representative within the next 16 hours.
Relieved by antacids or nitroglycerin, without other symptoms, but recurring more often than usual
Notify medical staff on the next business day
Relieved by antacids or nitroglycerin, without other symptoms, but recurring more often than usual
Notify medical staff at the next regular rounds
Gradual or persistent change in usual pattern, frequency, or nature of a chronic discomfort
SBAR Report
Situation: "Chest pain” (unrelieved by) (nitroglycerin) (antacids) “associated with:" (dyspnea) (diaphoresis) (dizziness) (low blood pressure) (tachycardia) (low oxygen saturation)
Background:
Reason the patient is in the nursing home (rehab for___, long term care for __).
History of heart problems, lung problems, stomach problems, recent trauma
Description of symptoms, when they started, how severe they are, getting worse or staying the same, anything that makes the symptoms worse, what treatments have been used.
Abnormal Vital Signs
MOLST / Advance Directives
Recent illness, antibiotics, medication changes, surgery, falls
General observation of patient condition
Abnormal findings on lung, cardiovascular, abdomen, or skin observations.
Oxygen use
Assessment: I am concerned about: __________
Recommendations/Requests:
Hospitalization (for unrelieved cardiac chest pain in a full-code patient)
Labs: CBC with diff, Troponin, BMP/Chem8
INR if patient is on warfarin
Chest X-ray with lateral view if possible
“Hold” parameters for medicines that lower blood pressure (other than nitrates and beta blockers)
EKG
Aspirin
Nitroglycerin
Oxygen
Antacid medication
Pain Medication
Other:
Clarify expectations for care, interventions, and illness course/prognosis. Repeat any telephone orders back to the provider to ensure that they are correct and complete
4. Implement Management Plan
Monitor vital signs every 4-8 hrs for 1-2 days
Place on Intake & Output monitoring
Place on 24-hour report for 2-3 days
Obtain lab results (if ordered), and notify medical as needed of:
Significantly abnormal values in lab tests (refer to appropriate Situation)
WBC > 12,000 or neutrophils > 90%
Infiltrate or pneumonia on chest x-ray
Update care plan regarding fall risk, pressure ulcer prevention, assistance needed with ADLs, supervision for safety, restorative needs
Review status and plan of care with designated representative with any changes
Update advance directives if appropriate
2025-04-26
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