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How to respond rapidly when chest pain strikes Fowler, John P. 1996): 42

Nursing; Philadelphia

Vol.

26,

Iss.

4,

(Apr

Abstract The presence of severe chest pain indicates that the clinical picture of a patient may be deteriorating--fast. Treatment options nurses should implement when encountering sudden chest pain in a patient are discussed.

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NONE OF THE ALARMS HAD SOUNDED in the step-down unit--not even the alarm for Hal Dalton. His monitor showed that he remained in a steady sinus rhythm. The only change from his admission for angina the previous day was a slightly elevated heart rate--up to90 from 78. So you're surprised when his call light flashes. When you respond, one glance at Mr. Dalton's face tells you he's in severe pain--and scared. Since his admission, Mr. Dalton's electrocardiograms (ECGs) and cardiac enzymes have been normal, despite a preadmission history of new-onset anginaand multiple risk factors, including smoking, hyperlipidemia, and obesity. But the presence of severe chest pain indicates that the clinical picture may be deteriorating--fast. Starting treatment stat After calling for assistance, you take Mr. Dalton's vital signs. His blood pressure (BP) is 170/110; respiratory rate, 24; and Spo2, 95%. You initiate oxygen via nasal connula at 3 liters/minute. Another nurse obtains a 12-lead ECG while you administer 0.4 mg sublingual nitroglycerin per Mr. Dalton's standing medication orders. In the meantime, you ask Mr. Dalton to rate his pain on a scale of 0 (none) to 10 (most severe). He rates it a 10. You also ask Mr. Dalton about the pain's location and

quality. He describes it as squeezing and radiating tohis neck. He also reports feeling nauseated and sweaty. The first nitroglycerin tablet brings his pain down to an 8. You repeat his BP (150/96) and give him a second sublingual nitroglycerin tablet. Five minutes later, per the physician's order, you also administer 2 mg of morphine, intravenous (I.V.) push over 2 minutes. After 20 minutes of treatment and an additional morphine dose, Mr. Dalton is pain-free and his BP is 130/80. The on-call resident reads his 12-lead ECG and confirms ischemic changes from the previous ECG, including T-wave inversions in leads II, III, and aVF, and ST-segment depression in leads, I, V5, and V6. He diagnoses unstable angina. You draw stat cardiac enzymes, to be repeated 8 and 16 hours later for comparison. Because Mr. Dalton's chest pain recurs a short time later, the physician orders a nitroglycerin drip that can be titrated to a maximum of 100 mcg/minute while maintaining a systolic BP of 100 mm Hg. (See Chest-Pain Drugs at a Glance.) He also orders aspirin, 324 mg P.O., and herapin, 5,000 units I.V. push, followed by a heparin drip at 1,000 units/hour, with an activated partial thromboplastin time to be drawn 5 hours later. While you give Mr. Dalton aspirin, your colleague arranges for his transfer to the coronary care unit (CCU). Classifying angina Mr. Dalton has unstable angina, which can occur at rest. Angina can be divided into three types. * Exertional angina. This common angina is defined as chest pain precipitated by the temporary interruption of the blood (an oxygen) supply to the coronary arteries. It's often associated with exertion or cold, which causes an imbalance between myocardial oxygen supply and demand. Contributing risk factors include smoking, hypertension, hyperlipidemia, obesity, diabetes, heredity, stress, and a sedentary lifestyle. These factors can contribute to the narrowing of coronary arteries, resulting in angina. * Unstable angina. The cause of Mr. Dalton's chest pain, unstable (or crescendo) angina is chest pain that occurs at rest or that has increased in frequency, duration, or intensity. These patients require more intense medical therapy and may be at high risk for an acute myocardial infarction (MI) or sudden death. A patient with unstable angina may need cardiac catheterization to determine the specific vessels involved and the amount of stenosis. Based on the results, he may

require a coronary angioplasty, arthrectomy, or other cardiac procedures to reestablish coronary blood flow. Coronary artery bypass graft surgery may also be an option if left main disease or triple-vessel disease is present. * Prinzmetal's angina. Another type of resting angina, Prinzmetal's (or variant) angina is usually the result of a lesion or coronary artery spasm. The ECG tracing of a patient with Prinzmetal's angina may mimic an acute MI, with ST-segment elevations. Accurate assessment and rapid treatment are required to avert an acute MI. The preferred treatments are nitrates and calcium channel blockers, particularly nifedipine (Procardia). Once the spasm is resolved, the ST-segment elevations usually return to baseline. Further treatment Unfortunately, Mr. Dalton experienced recurrent episodes of chest pain, requiring increasing doses of nitrates. Beta-blockers and calcium channel blockers were added tothe regimen. He underwent cardiac catheterization the next day and had an arthrectomy for left anterior descending and circumflex lesions. Later, while recovering in the CCU, his I.V. medications were changed to oral formulations and he was transferred back to your unit. He was discharged after 3 days free from recurrent chest pain. Your discharge teaching included instructions on medication guidelines, weight control, stress reduction, exercise, and symptoms that should prompt Mr. Dalton tocontact his health care provider immediately. Because of your initial rapid response and the continuing good care he received in the CCU, Mr. Dalton didn't have further cardiac damage and has the best chance for recovery.

References: Fowler, J. P. (1996). How to respond rapidly when chest pain strikes. Nursing, 26(4), 42. Retrieved from https://search.proquest.com/docview/204538110?accountid=35028