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.

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