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.

CLINICAL INFORMATION FOR NURSES

Dearnurses.net is no longer available.

Updated 1/25

Dear nurses,

New links have been added below.

Here are the topics:

IV assessment

Avoiding Medication errors

Neurological Assessment

Chest Pain Assessment

Chest pain assessment

The Numerical Pain Scale is a useful tool when
assessing pain. It is based on a scale of 0-10.

A ladder starts from the ground and escalates to
the highest point, so does pain start from 0-10.

It is important to do a pain assessment after pain
medication has been given. See image for more
information.

PAIN ASSESSMENT

Updated 6/25

Dear nurses,

It is important to recognize, when a patient
complains of pain, an assessment should be
done by the nurse. Below, examples of pain
assessment, with links, have been added.

Enjoy learning!

Learn more about : Chest pain assessment

Learn more about: Pain assessment

Learn more about: The standards of care

Learn more about:
Dehydration on a long flight
Abdominal Aortic Aneurysm

Be cautious, prevent falls!

NEUMERICAL PAIN SCALE ASSESSMENT

Scenario: Paul had surgery on his back two days prior.
He is having pain and requests medication. The nurse
does an assessment.

Neumerical pain scale assessment

This a very useful tool when assessing pain. It is
based on a scale of 0-10 ( 10 being the worst).
A ladder starts from the ground which is the
lowest point. It escalates to the highest point,
so does the pain. Pain scale:

0 = no pain
1-3 = mild pain
4-6 = pain is considered moderate
7-10 = pain is extreme or severe

Helpful hints:

Medication that is given by mouth, takes
longer to be absorbed than when it is given
IM or IV.

It is important to do a pain assessment after
medication has been given. Documentation
of the effect it has and any side effects, is
also helpful. Learn more:
Safe medication administration

Learn more : The Nursing Process

ADDRESSING PAIN ASSESSMENT

Updated 8/25

Dear nurses,

As we all know, pain is a common complaint.
It is important to recognize the cause, source
and to do an assessment on a scale of 1-10.

Pain medication is given to the patient complaining
of pain. Medication is usually ordered by the doctor.
The MAR is used for each patient.

Documentation of the pain medication given, the
pain scales from start to finish and the outcomes
of all medication, is also important.

Below are some scenarios associated with pain.

Learn more about: Aortic rupture

PACU

The nurse above is about to make a medication error.
This is very poor judgement on her part.

Here are some helpful pointers for good medication administration:
- Follow MD orders

- Remember the five or more rights
- DO NOT USE COLOR CODING AS YOUR ONLY GUIDELINE.
Remember, many pills may have the same color, but that does not
mean they are of equal strength.
- If you are a new nurse and you are uncertain, consult with a more
experienced nurse to help you out.

- Always follow your Institution's policies and procedures.

The Numerical Pain Scale is a useful tool when
assessing pain. It is based on a scale of 0-10.
A ladder starts from the ground and escalates to
the highest point, so does pain start from 0-10.

Learn more about: Chest pain assessment and

Triage Nurse

CARDIOGENIC SHOCK AND ASSESSMENT

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 shoulder/jaw, or it may feel like chest pressure.

Helpful Hint:
Chest pain should always be assessed.
Enjoy learning more about this topic by clicking on the link:
Simplifying Cardiogenic Shock

MYOCARDIAL INFARCTION - NURSING ASSESSMENT

Updated 12/25 Dearnurses.com is no longer available.

Dear nurses,

New topics and links have been added below.

The 12 lead EKG is done to analyze a myocardial
infarction's location. The electrical activity of the
heart is taken from 12 different angles, just like a
camera taking a picture from different views.

Learn more about this topic by watching the video:

The new nurse - Easy read EKG

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.

Helpful Hint:
Chest pain should always be assessed.
Enjoy learning more about this topic by clicking on the link:
Simplifying Cardiogenic Shock

How do you read an EKG?

P wave = atrial contraction
QRS waves = ventricular contraction
T wave = resting time before the next contraction

Learn more about this topic by watching the video:

The new nurse - Easy read EKG

Hemodynamics refers to blood flow. The heart is a pump,
which pumps blood around the body. If there is damage,
like a myocardial infarction, the heart's function will be

impaired.

Learn more about: Congestive heart failure

A patient who has a straight line on the monitor,

requires immediate intervention. The nurse should
check the patient to make sure an electrode is not
disconnected.

If there is no disconnection, the patient may have
gone into Cardiopulmonary arrest. This calls for
CPR.

A Cardiopulmonary arrest is called a Code Blue.
This means the heart has stopped beating and the
body's cells are deprived of blood supply and oxygen.

Immediate action is taken by the staff , to call a Code
Blue overhead. This summons trained personnel to
that patient's bedside.

PATIENT ASSESSMENT IS IMPORTANT

Updated 8/25

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 shoulder/jaw, or it may feel like chest pressure.

Helpful Hint:
Chest pain should always be assessed.
Enjoy learning more about this topic by clicking on the link:
Simplifying Cardiogenic Shock

Learn more about : ARDS, DVT and PE

A pneumothorax may occur as a result of a rib fracture.
The punctured lung, collapses.

Scenario: A patient was involved in a car accident.

Trauma to the chest area, has resulted in a pneumothorax.
He was also having difficulty breathing, so the medical team
initiated CPR and placed an ETT ( endotracheal tube).
Learn more about: Pneumothorax

ADDRESSING PATIENT ASSESSMENT

Updated 7/25

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 shoulder
/jaw, or it may feel like chest pressure.

Helpful Hint:
Chest pain should always be assessed.
Enjoy learning more about this topic by clicking on the link:
Simplifying Cardiogenic Shock

Scenario: In the image above, Ann is an opera
singer. While on stage, she suddenly starts having
trouble getting her words out. Her right arm also
feels weak. These symptoms are classic of someone
experiencing a stroke.

Signs and stroke symptoms:

- sudden , severe headache
- slurred speech, mental confusion

- nausea and vomiting

- visual disturbances, hearing loss

- facial weakness

- weakness in arm or leg on one side

A CAT scan or MRI or both may be done to
confirm diagnosis.

UNDERSTANDING VENTRICULAR TACHYCARDIA

Updated 9/25

Dear nurses,

The EKG Series is no longer available.

The image above demonstrates Ventricular Tachycardia.
Learn more by clicking on the link: Ventricular Tachycardia

It takes " all hands on deck" when an emergency occurs.
Learn more about: Hemodynamic Monitoring and

Cardiac Assessment.

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.

Helpful Hint:
Chest pain should always be assessed.
Enjoy learning more about this topic by clicking on the link:
Simplifying Cardiogenic Shock

CARDIOGENIC SHOCK ASSESSMENT

Updated 7/25

Scenario: Mrs. R is a 48 year-old female who has a
history of a previous myocardial infarction. 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 shoulder/jaw,
or it may feel like chest pressure.

Helpful Hint:
Chest pain should always be assessed.
Enjoy learning more about this topic by clicking on the link:
Simplifying Cardiogenic Shock

Learn more about : Organizational Skills

PAIN MANAGEMENT

Updated 6/25

Dear nurses,

It is important to remember that pain assessment,
should not be overlooked. Always follow MD orders

for pain management.

Documentation of pain relief is also necessary.

Chest pain is a very common complaint. It may
occur anywhere and anytime, even at rest.
Learn more about : Chest pain

The Numerical Pain Scale is a useful tool when
assessing pain. It is based on a scale of 0-10.
A ladder starts from the ground and escalates to|
the highest point, so does pain start from 0-10.

It is important to do a pain assessment after pain
medication has been given. See image for more
information.

CORRECT ASSESSMENT OF CHEST PAIN IN THE CLINICAL SETTING

Updated 5/26

Dearnurses.com is no longer available.

New information and links have been

added below.

Patient assessment is a very important tool.
The patient having chest pain, would have

an assessment done by the nurse.

A description of the pain, as well as pain
scales assessment ( 1-10) is usually done.

Documentation of intervention is also
necessary.

Below are more assessment links:
Neurological assessment
Abdominal assessment

Stroke assessment

Myocardial infarction - Nursing assessment

Learn more about this topic by watching the video:

The new nurse - Easy read EKG

Learn more about: Mitral valve regurgitation

CARDIOGENIC SHOCK AND CRITICAL THINKING

Updated 8/25

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 shoulder/jaw, or it may feel like chest pressure.

Helpful Hint:
Chest pain should always be assessed.
Enjoy learning more about this topic by clicking on the link:
Simplifying Cardiogenic Shock

Learn more about : ARDS, DVT and PE

Learn more about: Aortic Rupture

WHEN CPR IS NEEDED IN THE EMERGENCY ROOM

Updated 8/25

Dearnurses.net is no longer available.

New information has been added below.

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.

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.

Learn more about : ARDS, DVT and PE