Nursing Care Plan Chest Pain


Nursing Care Plan Chest Pain

What is nursing care plan for chest pain?

Nursing Management Manage chest pain. Bed rest. Provide oxygen. Administer aspirin and nitroglycerin. Place patient with head of the bed elevated at 45 degrees.

What is the intervention for a patient complaining of chest pain?

If you or someone else may be having a heart attack, follow these first-aid steps: –

  • Call 911 or emergency medical assistance. Don’t ignore the symptoms of a heart attack. If you can’t get an ambulance or emergency vehicle to come to you, have a neighbor or a friend drive you to the nearest hospital. Drive yourself only if you have no other option. Because your condition can worsen, driving yourself puts you and others at risk.
  • Chew aspirin. Aspirin is a blood thinner. It prevents clotting and keeps blood flowing through a narrowed artery that’s caused a heart attack. Don’t take aspirin if you have chest pain due to an injury. Also, don’t take aspirin if you are allergic to aspirin, have bleeding problems or take another blood-thinning medication, or if your health care provider previously told you not to do so.
  • Take nitroglycerin, if prescribed. If you think you’re having a heart attack and your health care provider has previously prescribed nitroglycerin for you, take it as directed. Don’t take anyone else’s nitroglycerin.
  • Begin CPR on the person having a heart attack. The American Heart Association recommends starting hands-only CPR. Push hard and fast on the person’s chest for 100 to 120 compressions a minute.
  • If an automated external defibrillator (AED) is immediately available and the person is unconscious, follow the device instructions for using it.

What is a Nanda approved nursing diagnosis for pain?

Diagnoses – Commonly used NANDA-I nursing diagnoses for pain include Acute Pain (duration less than 3 months) and Chronic Pain, See Table 11.5 for more information regarding these diagnoses. For more information about defining characteristics and related factors for other NANDA-I nursing diagnoses, refer to a current nursing diagnosis resource. Table 11.5 Pain NANDA-I Nursing Diagnoses

NANDA-I Diagnosis Definition Defining Characteristics
Acute Pain Unpleasant sensory and emotional experience associated with acute or potential tissue damage, or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end, and with a duration of less than 3 months.

Alteration in sleep pattern Appetite change Change in physiological parameters (i.e., blood pressure, heart rate, respiratory rate) Diaphoresis Distraction behavior Evidence of pain using standardized pain behavior checklist for those unable to communicate verbally Expressive behavior Facial expression of pain Guarding behavior Hopelessness Narrowed focus Protective behavior Proxy report of pain behavior/activity changes Pupil dilation Restlessness Self-focused Self-report of intensity using standardized pain scale Self-report of pain characteristics using standardized pain instrument

Chronic Pain Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe, constant or recurring without anticipated or predictable end, and with a duration of greater than 3 months.

Alteration in ability to continue previous activities Alteration in sleep pattern Anorexia Evidence of pain using standardized pain behavior checklist for those unable to communicate verbally Facial expression of pain Proxy report of pain behavior/activity changes Self-focused Self-report of intensity using standardized pain scale Self-report of pain characteristics using standardized pain instrument

What are the 5 components of nursing care plan?

Function – The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation. Assessment Assessment is the first step and involves critical thinking skills and data collection; subjective and objective.

Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight. Data may come from the patient directly or from primary caregivers who may or may not be direct relation family members. Friends can play a role in data collection.

Electronic health records may populate data and assist in assessment. Critical thinking skills are essential to assessment, thus the need for concept-based curriculum changes. Diagnosis The formulation of a nursing diagnosis by employing clinical judgment assists in the planning and implementation of patient care.

The North American Nursing Diagnosis Association (NANDA) provides nurses with an up-to-date list of nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical judgment about responses to actual or potential health problems on the part of the patient, family, or community. A nursing diagnosis encompasses Maslow’s Hierarchy of Needs and helps to prioritize and plan care based on patient-centered outcomes.

In 1943, Abraham Maslow developed a hierarchy based on basic fundamental needs innate to all individuals. Basic physiological needs/goals must be met before higher needs/goals can be achieved such as self-esteem and self-actualization. Physiological and safety needs provide the basis for the implementation of nursing care and nursing interventions.

  • Basic Physiological Needs: Nutrition (water and food), elimination (Toileting), airway (suction)-breathing (oxygen)-circulation (pulse, cardiac monitor, blood pressure) (ABCs), sleep, sex, shelter, and exercise.
  • Safety and Security: Injury prevention (side rails, call lights, hand hygiene, isolation, suicide precautions, fall precautions, car seats, helmets, seat belts), fostering a climate of trust and safety (therapeutic relationship), patient education (modifiable risk factors for stroke, heart disease).
  • Love and Belonging: Foster supportive relationships, methods to avoid social isolation (bullying), employ active listening techniques, therapeutic communication, and sexual intimacy.
  • Self-Esteem: Acceptance in the community, workforce, personal achievement, sense of control or empowerment, accepting one’s physical appearance or body habitus.
  • Self-Actualization: Empowering environment, spiritual growth, ability to recognize the point of view of others, reaching one’s maximum potential.
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Planning The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting.

  1. Care plans provide a course of direction for personalized care tailored to an individual’s unique needs.
  2. Overall condition and comorbid conditions play a role in the construction of a care plan.
  3. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum.

Goals should be:

  1. Specific
  2. Measurable or Meaningful
  3. Attainable or Action-Oriented
  4. Realistic or Results-Oriented
  5. Timely or Time-Oriented

Implementation Implementation is the step that involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care. This phase requires nursing interventions such as applying a cardiac monitor or oxygen, direct or indirect care, medication administration, standard treatment protocols, and EDP standards.

Evaluation This final step of the nursing process is vital to a positive patient outcome. Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. Reassessment may frequently be needed depending upon overall patient condition.

The plan of care may be adapted based on new assessment data.

What is the first nursing intervention for chest pain?

3. Decreasing Oxygen Demand and Managing Decreased Cardiac Output – The oxygen supply to organs depends on blood flow and oxygen saturation. The inability of coronary arteries in clients with atherosclerosis to increase blood flow during stress, leading to insufficient oxygen supply to the heart muscle, results in angina (Alaeddini & Yang, 2018). The following are therapeutic nursing interventions and actions to decrease oxygen demand for patients with angina: 1. Provide supplemental oxygen as indicated. Increases oxygen available for myocardial uptake and reversal of ischemia. All clients with acute ischemic pain are administered supplemental oxygen to increase myocardial oxygenation. Hypoxia is common because of the decreased perfusion which adds stress to the compromised myocardium.2. Observe associated symptoms such as dyspnea, nausea, vomiting, dizziness, palpitations, and desire to micturate. Decreased cardiac output (which may occur during the ischemic myocardial episode) stimulates the sympathetic and parasympathetic nervous system, causing a variety of vague sensations that the client may not identify as related to the anginal episode. A feeling of weakness or numbness in the arms, wrists, and hands, as well as shortness of breath, pallor, diaphoresis, dizziness, lightheadedness, and nausea and vomiting, may accompany the pain.3. Provide light meals with decreased saturated fats, decreased cholesterol, decreased sodium, and refined sugar. Have the client rest for one hour after meals. This decreases the myocardial workload associated with the work of digestion, reducing the risk of anginal attack. Reducing the dietary saturated fat and decreasing cholesterol intake is effective in lowering the risk of heart and blood vessel disease. Refined sugars are empty calories that can convert to fat stores. Increased sodium intake leads to water retention, which increases vascular volume and cardiac workload.4. Monitor vital signs and cardiac rhythm, Tachycardia may be present because of pain, anxiety, hypoxemia, and reduced cardiac output. Increases in heart rate and myocardial contractile state result in increased myocardial oxygen demand. Changes may also occur in BP ( hypertension or hypotension) because of cardiac response. ECG changes reflecting dysrhythmias indicate the need for additional evaluation and therapeutic intervention.5. Auscultate breath sounds and heart sounds. Listen for murmurs. S3, S4, or crackles can occur with cardiac decompensation or some medications (especially beta-blockers). Development of murmurs may reveal a valvular cause for chest pain (aortic stenosis, mitral stenosis) or papillary muscle rupture. A large area of myocardial jeopardy may manifest as signs of transient myocardial dysfunction and typically signifies a higher-risk situation (Tan & Yang, 2020).6. Note skin color and the presence and quality of pulses. Peripheral circulation is reduced when cardiac output falls, giving the skin a pale or gray color (depending on the level of hypoxia) and diminishing the strength of peripheral pulses.7. Monitor pulse oximetry or ABGs as indicated. The therapeutic effectiveness of oxygen is determined by pulse oximetry to maintain a normal oxygen saturation level greater than 95% unless the client has a history of chronic obstructive pulmonary disease and is a carbon dioxide retainer.8. Monitor laboratory studies especially PTT, and aPTT. The amount of heparin administered is based on the results of the activated partial thromboplastin time (aPTT). Heparin therapy is usually considered therapeutic when the aPTT is 1.5 to 2 times the normal aPTT.9. Measure cardiac output and other functional parameters as indicated. Cardiac index, preload/afterload, contractility, and cardiac work can be measured noninvasively through various means, including the thoracic electrical bioimpedance (TEB) technique. These are useful in evaluating responses to therapeutic interventions and identifying the need for emergency care. Note: Evaluation of changes in heart rate, BP, and cardiac output requires consideration of the client’s circadian hemodynamic variability.10. Place the client at complete rest during anginal episodes. This reduces myocardial oxygen demand to minimize the risk of tissue injury, A mismatch between myocardial oxygen supply and demand can result in myocardial ischemia or infarction. Infarct results in irreversible damage to the myocardium (Boyette & Manna, 2022).11. Maintain bed or chair rest in a position of comfort during acute episodes. This decreases oxygen demand, therefore, reducing myocardial workload and the risk of decompensation. Clients with unstable angina require admission to the hospital for bed rest with continuous telemetry monitoring (Tan & Yang, 2020).1 2. Provide adequate rest periods. Perform self-care activities, as indicated. This conserves energy and reduces cardiac workload. The level of activity that aggravates anginal symptoms is different for each client. However, most clients with stable angina can avoid symptoms during daily activities simply by reducing the speed of activity (Alaeddini & Yang, 2018).13. Stress the importance of avoiding straining down, especially during defecation. It is important to teach avoidance of the Valsalva maneuver, which is defined as forced expiration against a closed glottis. This can be explained to the client as “bearing down” during defecation or breath-holding when repositioning in bed. Valsalva maneuver causes vagal stimulation, reducing heart rate (bradycardia), which may be followed by rebound tachycardia, both of which may impair cardiac output.14. Administer supplemental oxygen as needed. Increases oxygen available for myocardial uptake to improve contractility, reduce ischemia, and reduce lactic acid levels. Oxygen therapy may be initiated at the onset of chest pain in an attempt to increase the amount of oxygen delivered to the myocardium and decrease pain. Oxygen therapy is indicated for clients with hypoxia (oxygen saturation <93%) and those with evidence of shock to correct tissue hypoxia.15. Discuss the purpose and prepare for stress testing and cardiac catheterization, when indicated. Stress testing provides information about the health and strength of the ventricles. Exercise stress testing can be performed alone and in conjunction with echocardiography or myocardial perfusion scintigraphy tests. Stress echocardiography has an overall sensitivity of 78% and a specificity of 77%. The gold standard of diagnostic testing for CAD is coronary angiography via cardiac catheterization. Arterial lesions or plaque are located and the amount of occlusion is determined.

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What is the first intervention for chest pain?

First aid for someone experiencing chest pain –

  1. Calm the person down and help them to rest, for example in a semi-seated position.
  2. Call 112 immediately. If the person is carrying their own nitrate medication (Nitro®), help them to take it. If the medication does not help within a few minutes, call 112.
  3. Give the person 250 mg of a medicine containing acetylsalicylic acid (Disperin®, Aspirin®) to be chewed if they are not allergic to the medicine.
  4. Monitor their breathing and circulation.
  5. If the person goes lifeless, start resuscitation with 30 presses and 2 blows, and notify the Emergency Response Centre about the change in the situation.

: How to give first aid for someone who is experiencing chest pain?

What is the management of chest pain?

Medications – Medicines used to treat some of the most common causes of chest pain include:

  • Artery relaxers. Nitroglycerin — usually taken as a tablet under the tongue — relaxes heart arteries so blood can flow more easily through the narrowed spaces. Some blood pressure medicines also relax and widen blood vessels.
  • Aspirin. If health care providers think that your chest pain is related to your heart, you’ll likely be given aspirin.
  • Clot-busting drugs, also called thrombolytics. If you are having a heart attack, you may receive these medicines. These work to dissolve the clot that is blocking blood from reaching the heart muscle.
  • Blood thinners. If you have a clot in an artery going to your heart or lungs, you’ll likely be given medicines to prevent more clots from forming.
  • Acid-reducing medicines. If chest pain is caused by stomach acid splashing into the esophagus, a health care provider may suggest these medicines. They reduce the amount of acid in the stomach.
  • Antidepressants. If you’re having panic attacks, your health care provider may prescribe antidepressants to help control symptoms. Talk therapy, such as cognitive behavioral therapy, also might be recommended.

What is the emergency for chest pain?

Calling 911 for Chest Pain – A visit to the ER for chest pain can be life-saving. When your chest pain persists, is severe, or is accompanied by shortness of breath, nausea, radiating pain, and changes in heart rate and blood pressure, call 911 immediately.

What is a good nursing plan?

SMART Goals – In the planning phase of writing a care plan, it’s important that you use goal-oriented strategies. A SMART goals template can help in this process:

Specific : Your goals for the patient must be well-defined and unambiguous. Measurable : You need to set certain metrics to measure the patient’s progress toward these goals. Achievable : Their goal should be possible to achieve. Realistic : Their goals must be within reach and relevant to the overall care plan. Time-bound : The patient’s goals should have a clear starting time and end date (which can be flexible).

What is an example of a nursing diagnosis?

What Are the Differences Between a Nursing Diagnosis and Other Types of Diagnosis? – Nursing diagnosis is not the only diagnosis one might come across in the process of care. That’s why it’s important to know the difference between different types of diagnosis.

The three main ones to consider are nursing diagnosis, medical diagnosis, and collaborative diagnosis. A nursing diagnosis refers to the process and, subsequently, the label nurses use to assign meaning to patient data collected in the Assessment phase. The data is labeled with NANDA-I approved nursing diagnosis.

For instance, while assessing a patient, the nurse may notice that the patient coughs prior to swallowing any food, displays inadequate laryngeal elevation, and repeatedly reports “something stuck” in their throat. The nurse can conclude a nursing diagnosis based on these symptoms: impaired swallowing,

  • Examples of nursing diagnosis : risk for impaired liver function; urinary retention; disturbed sleep pattern; decreased cardiac output.
  • On the other hand, a medical diagnosis is made by a doctor or advanced health care practitioner.
  • This type of diagnosis focuses on the patient’s disease, medical condition, or pathologic state – determining which falls into the expertise of advanced medical practitioners.

While the nursing diagnosis can be subject to change, the medical diagnosis generally doesn’t change. It remains imprinted on the patient’s medical history forever. Examples of medical diagnosis : atrial fibrillation; hepatitis; chronic kidney disease; hypertension.

What is the role of a chest pain nurse?

Rapid Access Chest Pain Clinic – The Chest Pain Nurse Specialist is a member of the clinical team at the John Radcliffe Rapid Access Chest Pain Clinic, a ‘one stop shop’ assessment and diagnostic service for people with suspected coronary heart disease.

How is chest pain triage?

Triage on admission according to the standard FRENCH scale – On admission, patients with chest pain were screened according to the 2018 version of the FRENCH scale, which is routinely used in our service. The scale has five levels of severity ranging from life-threatening conditions that require the immediate management of the patient (category 1) to non-urgent situations in which the patient should be seen within 4 hours (category 5).

The triage of chest pain patients according to the FRENCH scale is based on vital signs and the performance of a 12-lead ECG interpreted by a physician. If vital signs are outside the normal range and/or if ECG is indicative of ACS, the patient will be assigned to category 1. If ECG is abnormal but not indicative of ACS and the patient experiences typical chest pain, he or she will be assigned to category 2.

If ECG is normal but the patient has typical chest pain or coronary comorbidities, he or she will be assigned to category 3. If ECG is normal and the patient experiences atypical chest pain, he or she will be assigned to category 4. The respective maximum delays before medical intervention are no delay, 20, 60 and 120 minutes.

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What is the nursing care plan for patient?

Step 8: Evaluation – Evaluation is a planned, ongoing, purposeful activity in which the client’s progress towards achieving goals or desired outcomes is assessed, and the effectiveness of the nursing care plan (NCP). Evaluation is an essential aspect of the nursing process because the conclusions drawn from this step determine whether the nursing intervention should be terminated, continued, or changed.

What is the plan in a nursing care plan?

If you aspire to become a nurse, you’ll want to familiarize yourself with what nursing care plans (NCPs) are all about. Nursing care plans provide a means of communication among nurses, their patients, and other healthcare providers to achieve healthcare outcomes.

A nursing care plan contains relevant information about a patient’s diagnosis, the goals of treatment, the specific nursing orders (including what observations are needed and what actions must be performed), and an evaluation plan. Over the course of the patient’s stay, the plan is updated with any changes and new information as it presents itself.

In fact, most hospitals require nurses to update the care plan during and after each shift. Nursing care plans help define nursing guidelines and some treatment guidelines (as ordered) for a specific patient. Essentially, it is a plan of action. It helps guide nurses throughout their shift in caring for the patient.

  1. Informal – A care plan that exists in the nurse’s mind and is actions the nurse wishes to accomplish during their shift.
  2. Formal – This is a written or computerized plan that organizes and coordinates the patient’s care information and plan.
  3. Standardized – Nursing care for groups of patients with everyday needs.
  4. Individualized – A care plan tailored to the specific needs of the patient.

Nursing care plans follow a five-step process:

  • Assessment
  • Diagnosis
  • Expected outcomes
  • Interventions
  • Rationale and Evaluation

>> Related: The Nursing Process Explained When writing a nursing care plan, you first have to determine what type of care plan you are interested in. If it is for your own use throughout the shift, then an informal one may be beneficial; however, if it is for the patient’s chart and required during your shift then an individualized care plan is the way to go.

What is a care plan in nursing?

A nursing care plan is a road map for the care of a patient and a necessary tool in following the nursing process. Understanding nursing care plans is an important part of any nursing school curriculum and definitely something you’ll need to know as a nursing student.

In this guide, you’ll learn how to write and use a nursing care plan and why they’re important for maintaining quality patient care. Care plans play a vital role in the treatment of a patient. They clearly define guidelines along with the nurse’s role in patient care and help them create and achieve a solid plan of action.

This equips nurses to provide focused care—without overlooking important steps. Nursing care plans also promote: Collaboration

A well-documented care plan ensures the patient’s entire care team (doctors, nurses, etc.) can access the same information, give input, and join forces to provide the best care possible.


Care plans help nurses uphold the nursing code of ethics and provide a record that they did so in case of lawsuits or accusations that they failed to adhere to care standards.


A care plan is a communication tool for patient care between nurses. When nurses change shifts they’re able to reference the patient’s care plan to ensure the same quality care and interventions are being executed.

Without nursing care plans, nursing staff might have to rely on verbal communication and patient information could become more easily scattered or lost, all of which could result in improper patient care, Nursing care plans follow a five-step process: assessment, diagnosis, outcomes, implementation, and evaluation.

Assess the patient. The first step to writing a care plan is performing a patient assessment. This includes reviewing your patient’s medical history, diagnosis, lab values, and medications. This step is critical to creating an effective and accurate care plan for either short term or long term care. Make a diagnosis.

Nursing diagnoses differs from a medical diagnosis in that it’s based on the patient’s response to an illness, rather than the illness itself. Simply put, a nursing diagnosis is focused on patient care rather than treatment. According to NANDA (North American Nursing Diagnosis Association), a good nursing care plan should not only list each diagnosis but define it as well.

For example, acid reflux should be described as: “Ineffective airway clearance related to gastroesophageal reflux as evidenced by retching, upper airway congestion, and persistent coughing.” Set goals and outcomes. Once you’ve completed an assessment and diagnosis, it’s time to write down goals and a desired health care outcomes for your patient.

These describe what you hope to achieve in the short- and long-term future, provide direction for planning interventions, and serve as criteria for evaluating progress. Goals are documented in the patient’s care plan so that other nurses and health professionals caring for the patient have access to it.

Determine nursing interventions. At this point in the care plan, you’ll list all planned nursing interventions and document any that you’ve performed. You’ll write down things such as client responses to care, pain scale responses, medications given and their dosages, vital signs, etc. This communicates what nursing orders were implemented, what still needs to be done, and if the patient is ready to be discharged.

Evaluate the plan. Evaluation is necessary in a patient care plan to determine whether to continue, adjust, or terminate the plan of care. It measures the degree to which goals and outcomes are achieved and provides evidence for what factors positively or negatively impacted those goals.

Registered nurses and nurse practitioners use these plans in the nursing process as a road map for providing care. They’re also a tool to help nurses think critically and holistically to support the patient’s needs—physically, socially, spiritually, and psychosocially. Only RNs can develop the care plan and make changes, although LPNs can contribute suggestions.

A nursing care plan begins as soon as a patient is admitted and is updated frequently as their condition changes or after an evaluation. It’s an ongoing process that requires detailed, accurate documentation that strictly adheres to the nursing code of ethics, as well as HIPAA rules and regulations,