CHEST PAIN - ASSESSMENT, DOCUMENTATION AND INTERVENTION

Updated 10/25

Dear nurses,

New information and links on Chest pain assessment
has been added below.

Chest pain should always be assessed!

Learn more about: Chest pain assessment

The image above shows a Code blue in progress. This is 
happening in the emergency Room. Always follow your

Institution's policies and procedures for Code Blue. 

What is the role of the nurse who is assigned to the Code Blue?

The nurse has an important role in effective communication.
There are many responsibilities.

- staying calm in a chaotic situation
- giving clear instructions to coworkers
- ensuring that MD orders are conveyed correctly

- proper documentation of vital signs and all treatments /
  interventions that take place ( defibrillation for example)
  - the nurse becomes the " binding force

Scenario: Mrs. R is a 48 year-old female who has a history
of a previous myocardial infarction. She was admitted 2 days
 ago with mild chest pain. She was resting comfortably when
she suddenly started feeling short of breath. She is anxious 
and calls the nurse.

What actions did the nurse take?
-The nurse reassures Mrs. R. She does an assessment, vital signs
, and oxygen saturation. She gives oxygen per protocol.

The nurse notifies the doctor of what has occurred and her
assessment findings. She also mentions the vital signs, low
oxygen saturation, and steps that were taken to correct the
saturation. The doctor gives further orders, including a
transfer to CCU.

Why chest pain assessment?
It must be remembered that a patient with heart damage
 will also experience chest pain. Assessment of the pain
should also be included. This may be sharp, with radiation
 to the shoulder /jaw, or it may feel like chest pressure.