Nursing Care Plan For Chest Pain
- Manage chest pain.
- Bed rest.
- Provide oxygen.
- Administer aspirin and nitroglycerin.
- Place patient with head of the bed elevated at 45 degrees.
- Make patient comfortable.
- Hook up to monitor.
- Check vitals.
- 1 What is the nursing care plan?
- 2 What are the 5 points for cardiac assessment?
- 3 What does 5 mean in nursing?
How do you manage a patient with 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 the nursing care plan?
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,
What are the 5 points for cardiac assessment?
Heart Sounds – Auscultation is routinely performed over five specific areas of the heart to listen for corresponding valvular sounds. These auscultation sites are often referred to by the mnemonic “APE To Man,” referring to Aortic, Pulmonic, Erb’s point, Tricuspid, and Mitral areas (see Figure 9.8 for an illustration of cardiac auscultation areas).
- The aortic area is the second intercostal space to the right of the sternum.
- The pulmonic area is the second intercostal space to the left of the sternum.
- Erb’s point is directly below the pulmonic area and located at the third intercostal space to the left of the sternum.
- The tricuspid (or parasternal) area is at the fourth intercostal space to the left of the sternum.
The mitral (also called apical or left ventricular area) is the fifth intercostal space at the midclavicular line. Figure 9.8 Cardiac Auscultation Areas Auscultation usually begins at the aortic area (upper right sternal edge). Use the diaphragm of the stethoscope to carefully identify the S1 and S2 sounds. They will make a “lub-dub” sound. Note that when listening over the area of the aortic and pulmonic valves, the “dub” (S2) will sound louder than the “lub” (S1).
Move the stethoscope sequentially to the pulmonic area (upper left sternal edge), Erb’s point (left third intercostal space at the sternal border), and tricuspid area (fourth intercostal space. When assessing the mitral area for female patients, it is often helpful to ask them to lift up their breast tissue so the stethoscope can be placed directly on the chest wall.
Repeat this process with the bell of the stethoscope. The apical pulse should be counted over a 60-second period. For an adult, the heart rate should be between 60 and 100 with a regular rhythm to be considered within normal range. The apical pulse is an important assessment to obtain before the administration of many cardiac medications.
The first heart sound (S1) identifies the onset of systole, when the atrioventricular (AV) valves (mitral and tricuspid) close and the ventricles contract and eject the blood out of the heart. The second heart sound (S2) identifies the end of systole and the onset of diastole when the semilunar valves close, the AV valves open, and the ventricles fill with blood.
S1 corresponds to the palpable pulse. When auscultating, it is important to identify the S1 (“lub”) and S2 (“dub”) sounds, evaluate the rate and rhythm of the heart, and listen for any extra heart sounds. Listen to a normal S1/S2 sound. It may be helpful to use earbuds or a headphone:
- To effectively auscultate heart sounds, patient repositioning may be required. If it difficult to hear the heart sounds, ask the patient to lean forward if they are able, or lie on their left side. These positions moves the heart closer to their chest wall and can increase the volume of the heart sounds heard on auscultation. This repositioning may be helpful in clients with increased adipose tissue in their chest wall or larger breasts.
- It is common to hear lung sounds when auscultating the heart sounds. It may be helpful to ask the patient to briefly hold their breath if lung sounds impede adequate heart auscultation. Limit the holding of breath to 10 seconds or as tolerated by the patient.
- Environmental noise can cause difficulty in auscultating heart sounds. Removing environmental noise by turning down the television volume or shutting the door may be required for an accurate assessment.
- Patients may try to talk to you as you are assessing their heart sounds. It is often helpful to explain the procedure such as, “I am going to take a few minutes to listen carefully to the sounds of blood flow going through your heart. Please try not to speak while I am listening, so I can hear the sounds better.”
What are the nursing goals for heart failure?
References and Sources – Recommended journals, books, and other interesting materials to help you learn more about heart failure nursing care plans and nursing diagnosis:
- Albert, N.M. (2012). Fluid management strategies in heart failure, Critical care nurse, 32 (2), 20-32.
- Albert, N., Trochelman, K., Li, J., & Lin, S. (2010). Signs and symptoms of heart failure: are you asking the right questions?, American Journal of Critical Care, 19 (5), 443-452.
- Alkhawam, H., Abo-Salem, E., Zaiem, F., Ampadu, J., Rahman, A., Sulaiman, S., & Vittorio, T.J. (2019). Effect of digitalis level on readmission and mortality rate among heart failure reduced ejection fraction patients, Heart & Lung, 48 (1), 22-27.
- Allen, J.K., & Dennison, C.R. (2010). Randomized trials of nursing interventions for secondary prevention in patients with coronary artery disease and heart failure: systematic review, Journal of Cardiovascular Nursing, 25 (3), 207-220.
- Amin, A., Garcia Reeves, A.B., Li, X., Dhamane, A., Luo, X., Di Fusco, M., & Keshishian, A. (2019). Effectiveness and safety of oral anticoagulants in older adults with non-valvular atrial fibrillation and heart failure, PloS one, 14 (3), e0213614.
- Austin, J., Williams, R., Ross, L., Moseley, L., & Hutchison, S. (2005). Randomised controlled trial of cardiac rehabilitation in elderly patients with heart failure, European Journal of Heart Failure, 7 (3), 411-417.
- Barrese, V., & Taglialatela, M. (2013). New advances in beta-blocker therapy in heart failure, Frontiers in physiology, 4, 323.
- Bikdeli, B., Strait, K.M., Dharmarajan, K., Li, S.X., Mody, P., Partovian, C., & Krumholz, H.M. (2015). Intravenous fluids in acute decompensated heart failure, JACC: Heart Failure, 3 (2), 127-133.
- Bocchi, E.A. (2001). Cardiomyoplasty for treatment of heart failure, European journal of heart failure, 3 (4), 403-406.
- Bolger, A.P., Coats, A.J., & Gatzoulis, M.A. (2003). Congenital heart disease: the original heart failure syndrome, European Heart Journal, 24 (10), 970-976.
- Brater, D.C. (2000). Pharmacology of diuretics, The American journal of the medical sciences, 319 (1), 38-50.
- Brennan, E.J. (2018). Chronic heart failure nursing: integrated multidisciplinary care, British Journal of Nursing, 27 (12), 681-688.
- Brunner, L.S. (2010). Brunner & Suddarth’s textbook of medical-surgical nursing (Vol.1). Lippincott Williams & Wilkins.
- Butler, J., Young, J.B., Abraham, W.T., Bourge, R.C., Adams, K.F., Clare, R., & ESCAPE Investigators. (2006). Beta -blocker use and outcomes among hospitalized heart failure patients, Journal of the American College of Cardiology, 47 (12), 2462-2469.
- Cattadori, G., Segurini, C., Picozzi, A., Padeletti, L., & Anzà, C. (2018). Exercise and heart failure: an update, ESC heart failure, 5 (2), 222-232.
- Chew, H.S.J., Sim, K.L.D., & Cao, X. (2019). Motivation, challenges and self-regulation in heart failure self-care: a theory-driven qualitative study, International journal of behavioral medicine, 26 (5), 474-485.
- Conti, C.R. (2011). Intravenous morphine and chest pain, Clinical cardiology, 34 (8), 464.
- Cowie, M.R., & Mendez, G.F. (2002). BNP and congestive heart failure, Progress in cardiovascular diseases, 44 (4), 293-321.
- De Bruyne, L.K.M. (2003). Mechanisms and management of diuretic resistance in congestive heart failure, Postgraduate medical journal, 79 (931), 268-271.
- De Jong, M.J., Chung, M.L., Wu, J.R., Riegel, B., Rayens, M.K., & Moser, D.K. (2011). Linkages between anxiety and outcomes in heart failure, Heart & Lung, 40 (5), 393-404.
- Drazner, M.H., Rame, J.E., & Dries, D.L. (2003). Third heart sound and elevated jugular venous pressure as markers of the subsequent development of heart failure in patients with asymptomatic left ventricular dysfunction, The American journal of medicine, 114 (6), 431-437.
- Elkayam, U., Akhter, M.W., Tummala, P., Khan, S., & Singh, H. (2002). Nesiritide: a new drug for the treatment of decompensated heart failure, Journal of cardiovascular pharmacology and therapeutics, 7 (3), 181-194.
- Ellison, D.H., & Felker, G.M. (2017). Diuretic treatment in heart failure, New England Journal of Medicine, 377 (20), 1964-1975.
- Enright, P.L. (2003). The six-minute walk test, Respiratory care, 48 (8), 783-785.
- Faris, R.F., Flather, M., Purcell, H., Poole‐Wilson, P.A., & Coats, A.J. (2012). Diuretics for heart failure, Cochrane Database of Systematic Reviews, (2).
- Felker, G.M., Ellison, D.H., Mullens, W., Cox, Z.L., & Testani, J.M. (2020). Diuretic therapy for patients with heart failure: JACC state-of-the-art review, Journal of the American College of Cardiology, 75 (10), 1178-1195.
- Fletcher, G.F., Balady, G.J., Amsterdam, E.A., Chaitman, B., Eckel, R., Fleg, J., & Bazzarre, T. (2001). Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation, 104 (14), 1694-1740.
- Friederich, J.A., & Butterworth, J.F. (1995). Sodium nitroprusside: twenty years and counting, Anesthesia & Analgesia, 81 (1), 152-162.
- Gao, X., Peng, L., Adhikari, C.M., Lin, J., & Zuo, Z. (2007). Spironolactone reduced arrhythmia and maintained magnesium homeostasis in patients with congestive heart failure, Journal of cardiac failure, 13 (3), 170-177.
- Giordano, F.J. (2005). Oxygen, oxidative stress, hypoxia, and heart failure, The Journal of clinical investigation, 115(3), 500-508.
- Grady, K.L., Dracup, K., Kennedy, G., Moser, D.K., Piano, M., Stevenson, L.W., & Young, J.B. (2000). Team management of patients with heart failure: a statement for healthcare professionals from the Cardiovascular Nursing Council of the American Heart Association, Circulation, 102 (19), 2443-2456.
- Haque, W.A., Boehmer, J., Clemson, B.S., Leuenberger, U.A., Silber, D.H., & Sinoway, L.I. (1996). Hemodynamic effects of supplemental oxygen administration in congestive heart failure, Journal of the American College of Cardiology, 27 (2), 353-357.
- Herman, L.L., & Tivakaran, V.S. (2017). Hydralazine,
- Hinkle, J.L., & KH, C. (2017). Brunner & Suddarth’s textbook of medical‑surgical nursing. Vol.1.
- Holme, M.R., & Sharman, T. (2020). Sodium nitroprusside,
- Jaarsma, T., Strömberg, A., De Geest, S., Fridlund, B., Heikkila, J., Mårtensson, J., & Thompson, D.R. (2006). Heart failure management programmes in Europe, European Journal of Cardiovascular Nursing, 5 (3), 197-205.
- Jacobs, M. (1984). Mechanism of action of hydralazine on vascular smooth muscle, Biochemical pharmacology, 33 (18), 2915-2919.
- Joynt, K.E., Whellan, D.J., & O’connor, C.M. (2004). Why is depression bad for the failing heart? A review of the mechanistic relationship between depression and heart failure, Journal of cardiac failure, 10 (3), 258-271.
- Jurgens, C.Y., Goodlin, S., Dolansky, M., Ahmed, A., Fonarow, G.C., Boxer, R., & Rich, M.W. (2015). Heart failure management in skilled nursing facilities: a scientific statement from the American Heart Association and the Heart Failure Society of America, Circulation: Heart Failure, 8 (3), 655-687.
- Kemp, C.D., & Conte, J.V. (2012). The pathophysiology of heart failure, Cardiovascular Pathology, 21 (5), 365-371.
- Kim, W., & Kim, E.J. (2018). Heart failure as a risk factor for stroke, Journal of stroke, 20 (1), 33.
- Klompstra, L., Jaarsma, T., & Strömberg, A. (2018). Self-efficacy mediates the relationship between motivation and physical activity in patients with heart failure, The Journal of cardiovascular nursing, 33 (3), 211.
- Krämer, B.K., Schweda, F., & Riegger, G.A. (1999). Diuretic treatment and diuretic resistance in heart failure, The American journal of medicine, 106 (1), 90-96.
- Leier, C.V., & Chatterjee, K. (2007). The physical examination in heart failure—Part I, Congestive Heart Failure, 13 (1), 41-47.
- Levy, P., Compton, S., Welch, R., Delgado, G., Jennett, A., Penugonda, N., & Zalenski, R. (2007). Treatment of severe decompensated heart failure with high-dose intravenous nitroglycerin: a feasibility and outcome analysis, Annals of emergency medicine, 50 (2), 144-152.
- Lewis, P.A., Ward, D.A., & Courtney, M.D. (2009). The intra-aortic balloon pump in heart failure management: implications for nursing practice, Australian critical care, 22 (3), 125-131.
- Maisel, W.H., & Stevenson, L.W. (2003). Atrial fibrillation in heart failure: epidemiology, pathophysiology, and rationale for therapy, The American journal of cardiology, 91 (6), 2-8.
- Masip, J., Gayà, M., Páez, J., Betbesé, A., Vecilla, F., Manresa, R., & Ruíz, P. (2012). Pulse oximetry in the diagnosis of acute heart failure, Revista Española de Cardiología (English Edition), 65 (10), 879-884.
- Milo-Cotter, O., Cotter, G., Kaluski, E., Rund, M.M., Felker, G.M., Adams, K.F., & Weatherley, B.D. (2009). Rapid Clinical Assessment of Patients with Acute Heart Failure: First Blood Pressure and Oxygen Saturation–Is That All We Need ?, Cardiology, 114 (1), 75-82.
- Mullens, W., Abrahams, Z., Francis, G.S., Skouri, H.N., Starling, R.C., Young, J.B., & Tang, W.W. (2008). Sodium nitroprusside for advanced low-output heart failure, Journal of the American College of Cardiology, 52 (3), 200-207.
- Nicholson, C. (2007). Heart failure: A clinical nursing handbook (Vol.31). John Wiley & Sons.
- Nyolczas, N., Dekany, M., Muk, B., & Szabo, B. (2017). Combination of hydralazine and isosorbide-dinitrate in the treatment of patients with heart failure with reduced ejection fraction, Heart Failure: From Research to Clinical Practice, 31-45.
- Oh, S.W., & Han, S.Y. (2015). Loop diuretics in clinical practice, Electrolytes & Blood Pressure, 13 (1), 17-21.
- Pereira, J.D.M.V., Cavalcanti, A.C.D., Lopes, M.V.D.O., Silva, V.G.D., Souza, R.O.D., & Gonçalves, L.C. (2015). Accuracy in inference of nursing diagnoses in heart failure patients, Revista brasileira de enfermagem, 68, 690-696.
- Picano, E., Gargani, L., & Gheorghiade, M. (2010). Why, when, and how to assess pulmonary congestion in heart failure: pathophysiological, clinical, and methodological implications, Heart failure reviews, 15 (1), 63-72.
- Piña, I.L., Apstein, C.S., Balady, G.J., Belardinelli, R., Chaitman, B.R., Duscha, B.D., & Sullivan, M.J. (2003). Exercise and heart failure: a statement from the American Heart Association Committee on exercise, rehabilitation, and prevention, Circulation, 107 (8), 1210-1225.
- Platz, E., Merz, A.A., Jhund, P.S., Vazir, A., Campbell, R., & McMurray, J.J. (2017). Dynamic changes and prognostic value of pulmonary congestion by lung ultrasound in acute and chronic heart failure: a systematic review, European journal of heart failure, 19 (9), 1154-1163.
- Qamer, S.Z., Malik, A., Bayoumi, E., Lam, P.H., Singh, S., Packer, M., & Ahmed, A. (2019). Digoxin use and outcomes in patients with heart failure with reduced ejection fraction, The American journal of medicine, 132 (11), 1311-1319.
- Redeker, N.S., Adams, L., Berkowitz, R., Blank, L., Freudenberger, R., Gilbert, M., & Rapoport, D. (2012). Nocturia, sleep and daytime function in stable heart failure. Journal of Cardiac Failure, 18 (7), 569-575,
- Reid, M.B., & Cottrell, D. (2005). Nursing care of patients receiving: Intra-aortic balloon counterpulsation. Critical care nurse, 25 (5), 40-49.
- Rogers, C., & Bush, N. (2015). Heart failure: Pathophysiology, diagnosis, medical treatment guidelines, and nursing management, The Nursing Clinics of North America, 50 (4), 787-799.
- Rutledge, T., Reis, V.A., Linke, S.E., Greenberg, B.H., & Mills, P.J. (2006). Depression in heart failure: a meta-analytic review of prevalence, intervention effects, and associations with clinical outcomes, Journal of the American college of Cardiology, 48 (8), 1527-1537.
- Scott, L.D., Setter-Kline, K., & Britton, A.S. (2004). The effects of nursing interventions to enhance mental health and quality of life among individuals with heart failure, Applied Nursing Research, 17 (4), 248-256.
- Serber, S.L., Rinsky, B., Kumar, R., Macey, P.M., Fonarow, G.C., & Harper, R.M. (2014). Cerebral blood flow velocity and vasomotor reactivity during autonomic challenges in heart failure, Nursing research, 63 (3), 194.
- Sica, D.A., Carter, B., Cushman, W., & Hamm, L. (2011). Thiazide and loop diuretics, The journal of clinical hypertension, 13 (9), 639-643.
- Volterrani, M., & Iellamo, F. (2016). Cardiac Rehabilitation in patients with heart failure: New perspectives in exercise training, Cardiac failure review, 2 (1), 63.
- Yancy, C.W., Jessup, M., Bozkurt, B., Butler, J., Casey Jr, D.E., Colvin, M.M., & Westlake, C. (2017).2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America, Journal of the American College of Cardiology, 70 (6), 776-803.
- Zhao, X., Zhang, D.Q., Song, R., & Zhang, G. (2020). Nesiritide in patients with acute myocardial infarction and heart failure: a meta-analysis, Journal of International Medical Research, 48 (1), 0300060519897194.
- Ziaeian, B., Fonarow, G.C., & Heidenreich, P.A. (2017). Clinical effectiveness of hydralazine–isosorbide dinitrate in African-American patients with heart failure, JACC: Heart Failure, 5 (9), 632-639.
Originally published on July 14, 2013.
What is the emergency response for chest pain?
Immediate action required: Phone 999 immediately if: central chest pain or discomfort in the chest that doesn’t go away – it may feel like pressure, tightness or squeezing. pain that radiates down the left arm, or both arms, or to the neck, jaw, back or stomach. unconsciousness.
What are 4 causes of chest pain?
Chest pain can come from heart, lung, digestive or other issues. GERD, or heartburn, is the most common cause.
What are common nursing interventions?
What are nursing interventions? – Nursing interventions are simply any action a nurse performs to help patients reach expected outcomes. Providing physical treatments, emotional support, and patient education are all examples of nursing interventions. Nurses typically perform these actions as part of a nursing care plan to monitor and improve their patient’s comfort and health.
What does 5 mean in nursing?
More Definitions of Registered Nurse – Level 5 Registered Nurse – Level 5 means a Registered Nurse who is appointed as Director of Care/Nursing and who is a member of the executive management team, responsible and accountable for the overall coordination of the delivery of care services.
What is the abbreviation of the 5 steps in nursing process?
ADPIE is an acronym used to remember the five consecutive steps of the nursing process, which include assessment, diagnosis, planning, implementation, and evaluation. Ensuring all five stages of the nursing process are completed is essential in securing systematic, individualized patient care.
What are the 5 steps of the nursing process quizlet?
The nursing process involves five steps: assessment, diagnosis, planning, implementation, and evaluation.