Comfort: Chest Pain

Comfort: Chest Pain

Related To:
[Check those that apply]
(_) Myocardial Infarction
(_) Unstable Angina
(_) Coronary Artery Disease
(_) Chest Trauma
(_) Stress Anxiety
(_) Musculoskeletal Disorders
(_) Pulmonary, Myocardial contusion
(_) Other:_____________________________
____________________________________
____________________________________

As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) Person reports or demonstrates a discomfort.
Minor:
(
May be present)
(_) Increased BP (_) Diaphoresis (_) Dilated pupils (_) Restlessness
(_) Facial mask of pain (_) Crying/moaning (_) Short of breath (_) Anxiety

Date &
Sign.
Plan and Outcome
[Check those that apply]
Target
Date:
Nursing Interventions
[Check those that apply]
Date
Achieved:
The patient will:

(_) Verbalize relief/control of pain.

(_) Verbalize causative factors associated with chest pain.

(_) Other:

(_) Assess for causative factors asssociated:
  • Activity
  • Stress
  • Eating
  • Bowel elimination
  • Previous angina attack
  • Other:

(_) Assess characteristing of chest pain.

  • Location
  • Intensity (Scale 1-10)
  • Duration
  • Quality
  • Radiation

(_) Review history of previous pain experienced by patient and compare to current experience.

(_) Instruct patient to report pain immediately.

(_) Continuous EKG monitoring; note and record pattern during pain. Obtain STAT 12-lead EKG per policy for acute changes noted on continuous monitor.

(_) Provide a quiet, restful environment.

(_) As per physician order, administer IV analgesics in small increments until pain is relieved or maximum dose is achieved. Monitor BP during administration of pain meds. Assess pt. response to pain medication and notify physician if pain is not controlled or pt. experiences adverse reaction (decreased BP, HA, distress).

(_) Administer nitroglycerine as ordered by physician. Monitor as stated above.

(_) Titrate IV Nitro to achieve pain relief as ordered by physician. Monitor hemodynamic response to medication (BP, urine output).

(_) Administer supplemental oxygen as ordered by physician.

(_) Assist with ADL's to reduce cardiac stressors.

(_) Assist in eliminating causative factors as identified by patient assessment.

(_) Other:________________
________________________
________________________
________________________

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Patient/Significant other signature

__________________________
RN signature

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