Nursing Care Plan for Chest Pain

Chest pain is feeling pain / bad that disrupt the chest area and often the pain is projected on the chest wall.

Chest pain varies from person to person. It may feel like a sharp, stabbing pain or a dull ache. While chest pain may be a sign of a serious heart-related problem, it may also have other common, non–life-threatening causes.

Causes of Chest Pain

• heart attack
• angina—chest pain due to blockages in the blood vessels leading to your heart
• pericarditis—inflammation of the sac around the heart
• myocarditis—inflammation of the heart muscle
• cardiomyopathy—heart muscle disease
• aortic dissection—a rare condition involving rupture of the heart’s main artery

Signs and symptoms that commonly accompany chest pain are:

• Heartburn
• Headache
• Pain is projected to arms, neck, back
• Diaphoresis / cold sweat
• Shortness of breath
• Tachycardia
• Pale Skin
• Difficulty sleeping (insomnia)
• Nausea, Vomiting, Anorexia
• Anxiety, restlessness, focus on yourself
• Weakness
• Tense face, moaning, crying

Primary assessment

a. Airway

• How airway patency?
• Is there a blockage / buildup of secretions in the airway?
• How breath sounds?

b. Breathing

• How breathing pattern? Frequency? The depth and rhythm?
• Is using a respirator muscles?
• Are there additional breath sounds?

c. Circulation

• What about the peripheral and carotid pulse? Quality (content and voltage)
• How Capillary refillnya, if there akral cold, cyanosis or oliguric?
• Is there a loss of consciousness?
• How vital signs? blood pressure, temperature, pulse, respiration?

Secondary assessment

Important things that need to be studied further in chest pain (coronary):

a. Location of pain.
Where to place the start, spreading (coronary chest pain: from sternal spread to the neck, chin or shoulder to the left forearm ulna).

b. The nature of the pain.
Feeling of fullness, heaviness such as seizures, squeezing, stabbing, choking / burning, etc..

c. Characteristic pain.
The degree of pain, duration, number of times arise within a certain period.

d. Chronology of pain.
Early pain relief and development sequentially.

e. Circumstances at the time of the attack
Are arise at times / circumstances.

f. Factors that reinforce / relieve pain such as attitude / position of the body, movement, pressure, etc..

g. Other symptoms that may be present or not relations with chest pain.


Nursing Diagnosis for Chest Pain

1.  Acute pain r / t tissue ischemia secondary to arterial occlusion, tissue inflammation.
2. Ineffective Tissue perfusion (heart muscle) r / t decrease in blood flow.
3.  Activity intolerance r / t imbalance between oxygen supply and tissue metabolic needs.

Interventions:

• Bed rest with Fowler position / semi-Fowler.
• Perform a 12 lead ECG, 24-lead if necessary.
• Observing vital signs.
• Collaboration of O2 and administration of analgesic medications, tranquilizers, nitroglycerin, calcium antagonists and observation of drug side effects.
• Installing a drip and give peace to the client.
• Taking blood samples.
• Reduce environmental stimuli.
• Calm in the works.
• Observing signs of complications.