Chest pain, medically termed angina, is a significant symptom that arises when the heart muscle doesn’t receive sufficient oxygen. It’s crucial to understand that chest pain isn’t a disease itself, but rather a signal indicating an underlying health issue. Recognizing and addressing chest pain promptly is vital in healthcare, particularly in nursing practice.
The discomfort associated with angina can manifest in various ways, often described as squeezing, dull, sharp, crushing, or burning sensations. In severe cases, patients might express it as an intense pressure, akin to a heavy weight pressing down on their chest. This pain can also radiate to other areas such as the neck, jaw, or even the extremities, adding to the complexity of diagnosis and patient experience.
Understanding the Types of Chest Pain
Chest pain is fundamentally a symptom stemming from an underlying condition. These conditions can range from cardiovascular issues like coronary artery disease (CAD) and coronary microvascular disease (MVD) to non-cardiac problems such as pleuritis, pulmonary embolism, pneumothorax, and gastroesophageal reflux disease (GERD).
Angina pectoris, or chest pain, is categorized into several types, each with distinct characteristics:
- Stable Angina: Often referred to as exertional angina, stable angina is typically a predictable pattern of chest pain. It occurs primarily due to CAD, where narrowed or blocked arteries reduce oxygenated blood flow to the heart muscle. This type of chest pain is usually triggered by physical exertion or emotional stress and subsides with rest or medication, such as nitroglycerin.
- Unstable Angina: This form of angina is characterized by its unpredictable and often sudden onset. Unstable angina chest pain usually occurs even at rest, signaling a more critical condition. It is frequently caused by the rupture of an unstable plaque in a coronary artery, leading to a sudden reduction in blood flow. Unstable angina is a medical emergency requiring immediate diagnosis and treatment to prevent myocardial infarction.
- Variant (Prinzmetal) Angina: Also known as vasospastic angina, variant angina is caused by a spasm in the coronary arteries. This spasm temporarily narrows the artery, reducing blood flow and causing pain. Uniquely, variant angina often occurs at rest, typically between midnight and early morning. It is less directly related to plaque buildup and more to artery function.
Risk Factors Associated with Chest Pain
Several risk factors significantly increase the likelihood of experiencing angina. Identifying these risk factors is crucial for both preventative measures and patient education:
- High Cholesterol: Elevated levels of LDL cholesterol contribute to plaque formation in arteries, narrowing them and reducing blood flow to the heart.
- Hypertension: Hypertension, or high blood pressure, puts extra strain on the heart and arteries, accelerating the process of atherosclerosis and increasing the risk of angina.
- Smoking: Smoking damages blood vessels, promotes plaque buildup, and reduces the oxygen-carrying capacity of blood, significantly increasing the risk of chest pain and heart disease.
- Overweight or Obesity: Obesity is linked to several risk factors for heart disease, including high cholesterol, hypertension, and diabetes, all of which contribute to angina.
- Diabetes: Diabetes increases the risk of heart disease by damaging blood vessels and nerves, and by often co-existing with other risk factors like hypertension and high cholesterol.
- Metabolic Syndrome: This cluster of conditions, including increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels, significantly raises the risk of heart disease and angina.
- Sedentary Lifestyle: Lack of physical activity contributes to obesity, high cholesterol, and hypertension, all of which are risk factors for angina.
- Unhealthy Diet: Diets high in saturated and trans fats, cholesterol, and sodium can lead to high cholesterol, obesity, and hypertension, increasing the risk of angina.
- Family History of Heart Disease: A family history of early heart disease increases an individual’s risk, suggesting a genetic predisposition to conditions that cause angina.
- Older Age: The risk of angina increases with age, particularly for men over 45 and women over 55, as arteries naturally become stiffer and more prone to plaque buildup over time.
Prompt diagnosis and treatment of chest pain are crucial to prevent severe complications such as myocardial infarction. A thorough physical assessment and risk factor identification are essential first steps. Diagnostic examinations, including an electrocardiogram (ECG), blood tests, stress tests, coronary angiography, chest X-ray, cardiac catheterization, and computed tomography angiography (CTA), play a vital role in confirming the diagnosis and guiding the treatment of the underlying condition causing chest pain.
The Nursing Process and Chest Pain Management
Nurses are instrumental in the comprehensive management of patients experiencing chest pain. A thorough pain assessment is a cornerstone of nursing care, facilitating prompt and accurate diagnosis and subsequent treatment.
The primary goals of treatment for patients presenting with chest pain include:
- Accurate Identification: Determining the specific type of angina and its root cause is paramount for effective treatment.
- Immediate and Appropriate Intervention: Timely treatment is crucial, especially in cases of unstable angina or suspected myocardial infarction.
- Pain Relief and Vasodilation: Medications are used to alleviate pain and improve blood flow through vasodilation.
- Myocardial Preservation: In cases where myocardial infarction is a concern, treatment focuses on preserving heart muscle function and minimizing damage.
- Lifestyle Modifications: Long-term management involves educating patients on lifestyle changes to mitigate risk factors and prevent future episodes.
Patient education is a nursing priority. Patients need to be well-informed about recognizing the symptoms of stable versus unstable angina, understanding their treatment plans, and knowing when to seek immediate emergency assistance. Empowering patients with knowledge enables them to actively participate in their care and improve outcomes.
Nursing Care Plans for Chest Pain: Addressing Acute Pain
Once nursing diagnoses are established for a patient with chest pain, nursing care plans become essential tools for prioritizing assessments and interventions. These plans guide both short-term and long-term care goals. Among the critical nursing diagnoses for chest pain is Acute Pain.
Acute Pain
Patients experiencing chest pain often describe it using various terms such as squeezing, tight, sharp, or dull. The pain can sometimes be mistaken for indigestion due to its burning sensation. A classic description is a feeling of pressure, often likened to “an elephant sitting on my chest,” highlighting the intensity and oppressive nature of the pain.
Nursing Diagnosis: Acute Pain
Related to:
- Myocardial injury: Damage to the heart muscle tissue.
- Ischemia: Insufficient blood flow and oxygen supply to the heart muscle.
- Disease process: Underlying conditions such as CAD.
- Physical exertion: Activity that increases cardiac workload and oxygen demand.
As evidenced by:
- Diaphoresis: Excessive sweating, often associated with pain and stress.
- Distraction behavior: Actions taken to divert attention from pain, such as restlessness or fidgeting.
- Expressions of chest pain/pressure/tightness: Verbal and nonverbal communication of pain experience.
- Facial expression of pain: Grimacing, wincing, or other facial cues indicating pain.
- Guarding behavior: Protecting the chest area from movement or pressure to minimize pain.
- Positioning to ease pain: Assuming specific body positions to find relief.
- Clutching of chest: Holding or grabbing the chest area in response to pain.
- Tachycardia: Increased heart rate, a physiological response to pain and stress.
Expected outcomes:
- Patient will report a significant reduction in chest pain to a manageable level within a specified timeframe (e.g., within 1 hour of intervention).
- Patient will be able to identify and verbalize potential triggers or exacerbating factors of their chest pain.
Assessment:
1. Assess pain characteristics thoroughly, noting location, quality, intensity, onset, duration, precipitating and relieving factors. A comprehensive pain assessment is crucial. Utilize pain assessment tools like the PQRST (Provoking factors, Quality, Region/Radiation, Severity, Timing) or OLDCARTS (Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Treatment, Severity) to systematically gather data. Distinguishing the onset of chest pain, factors that trigger it, its characteristics (sharp, dull, etc.), duration, and precise location is vital for accurate diagnosis and effective management. For example, pain that radiates to the left arm or jaw, described as crushing, and associated with shortness of breath is highly indicative of cardiac ischemia.
2. Review and interpret diagnostic test results, particularly a 12-lead ECG. A 12-lead ECG is a critical diagnostic tool in the initial assessment of chest pain. It is often obtained immediately to either confirm or rule out acute myocardial infarction (MI). ECG changes such as ST-segment elevation or depression, T-wave inversions, or Q waves can provide rapid insights into cardiac ischemia or injury. Additionally, review other relevant diagnostic tests like cardiac enzymes (troponin), chest X-rays, and blood work to gain a holistic understanding of the patient’s condition.
3. Elicit a detailed history of chest pain, including previous episodes and their characteristics. Inquiring about a patient’s history of chest pain is essential. Determine if the patient has experienced chest pain before, and if so, whether the current pain episode feels similar to previous ones or if it’s a new or different type of pain. Understanding the patient’s pain history helps in differentiating between chronic stable angina and acute coronary syndromes, guiding immediate treatment decisions and risk stratification.
Interventions:
1. Administer pain medications promptly as prescribed, and evaluate their effectiveness. Pharmacological management is a cornerstone of acute pain relief in chest pain. Drug therapy aims to alleviate pain, reduce myocardial workload, and prevent complications such as myocardial infarction. Common medications include short-acting nitrates (e.g., nitroglycerin) for immediate vasodilation and pain relief, analgesics (e.g., morphine) for severe pain, angiotensin-converting enzyme (ACE) inhibitors, and calcium channel blockers to improve myocardial perfusion and reduce cardiac workload. Regularly assess the patient’s pain level using a pain scale before and after medication administration to evaluate the effectiveness of the intervention and adjust treatment as needed.
2. Provide supplemental oxygen therapy as indicated by the patient’s oxygen saturation levels and clinical status. Oxygen supplementation is a crucial intervention to increase oxygen delivery to the myocardium, especially when chest pain is suspected to be cardiac in origin. Monitor the patient’s oxygen saturation continuously using pulse oximetry. If oxygen saturation is below the prescribed target range (typically >94% unless COPD is present) or if the patient is exhibiting signs of respiratory distress, administer supplemental oxygen via nasal cannula or face mask as per physician orders. However, it’s important to note that routine oxygen supplementation in patients with normal oxygen saturation and uncomplicated chest pain may not be beneficial and should be guided by clinical assessment.
3. Prepare the patient for further diagnostic testing and procedures as indicated, and provide clear explanations to reduce anxiety. Depending on the initial assessment and ECG findings, further diagnostic tests are often necessary to determine the underlying cause of chest pain and guide long-term management. Prepare the patient physically and emotionally for procedures such as stress tests (exercise or pharmacological), echocardiograms, coronary CT angiography (CTA), or cardiac catheterization. Explain the purpose of each test, what to expect during the procedure, and the importance of these tests in diagnosing and managing their condition. Clear and honest communication can significantly alleviate patient anxiety and promote cooperation with the diagnostic process.
4. Deliver comprehensive patient education on chest pain management, including medication administration, symptom recognition, and when to seek emergency medical assistance. Patient education is paramount for long-term management and secondary prevention. Ensure the patient understands how to recognize the characteristics of their angina, especially differentiating between stable and unstable patterns. Teach them about the proper administration of prescribed medications, such as nitroglycerin tablets or sprays, including dosage, frequency, and potential side effects. Emphasize the critical importance of seeking immediate emergency medical assistance if they experience worsening chest pain, pain at rest (unstable angina), or new or different symptoms. Provide written educational materials and resources to reinforce verbal instructions and support patient understanding and adherence to the treatment plan.
Addressing Anxiety, Decreased Cardiac Output, and Tissue Perfusion Risks
Beyond acute pain, other significant nursing diagnoses for patients with chest pain include anxiety, decreased cardiac output, risk for decreased cardiac tissue perfusion, and risk for unstable blood pressure. These are briefly outlined below, mirroring the structure of the original article, while focusing on maintaining conciseness and relevance.
Anxiety
The experience of chest pain and its associated symptoms can understandably provoke fear and anxiety in patients.
Nursing Diagnosis: Anxiety
Related to:
- Potential threat of death: Fear associated with cardiac events.
- Unfamiliar situation: Hospitalization and medical procedures.
- Threat to change in health status: Uncertainty about the future and health outcomes.
As evidenced by:
- Expresses alarm, fear, panic.
- Nausea.
- Dry mouth.
- Palpitations.
- Inability to focus.
- Tachycardia, Tachypnea, Diaphoresis.
Expected outcomes:
- Patient will verbalize effective coping strategies to manage fear and anxiety related to chest pain.
- Patient will express a sense of safety and reduced fear.
Assessment:
1. Assess the patient’s feelings of fear and anxiety. Engage in therapeutic communication to explore the patient’s specific thoughts and feelings. Allowing the patient to verbalize their concerns is the first step in alleviating unnecessary fear and providing reassurance.
Interventions:
1. Provide verbal and physical reassurance of safety. Offer consistent support and reassurance while the patient expresses their emotions. Simple gestures like calmly rubbing the patient’s back or holding their hand can provide significant physical and emotional support.
2. Explore positive coping mechanisms. Teach and encourage the use of relaxation techniques such as deep breathing exercises or distraction methods to help manage anxiety and alarming symptoms like chest pain and dyspnea.
3. Administer anti-anxiety medications as prescribed. In cases of severe anxiety that is counterproductive to recovery, benzodiazepines may be prescribed to promote relaxation and reduce fear. Monitor for effectiveness and side effects.
4. Provide knowledge and education. Once the acute threat has subsided, educate the patient about their chest pain, symptoms, and treatment plan. Increased knowledge and understanding can empower the patient and reduce anxiety by fostering a sense of control.
Decreased Cardiac Output
Reduced cardiac output can result from insufficient blood flow to the heart, leading to chest pain and inadequate oxygenated blood supply throughout the body.
Nursing Diagnosis: Decreased Cardiac Output
Related to:
- Ineffective cardiac muscle contraction.
- Conditions compromising blood supply (narrowed/blocked arteries, plaque rupture, vasospasm).
- Heart structure malfunctions.
- Difficulty of the heart muscle to pump effectively.
As evidenced by:
- Increased central venous pressure (CVP).
- Tachycardia, Dysrhythmias.
- Ejection fraction less than 40%.
- Decreased oxygen saturation.
- Abnormal heart sound S4.
- Chest pain (angina), Hypertension.
- Dyspnea, Tachypnea.
- Altered level of consciousness, Restlessness.
- Fatigue, Activity intolerance.
- Cold, clammy skin.
- Prolonged capillary refill time.
- Edema.
Expected outcomes:
- Patient will demonstrate adequate cardiac output, evidenced by normal sinus rhythm on ECG.
- Patient will maintain hemodynamic stability, with vital signs within normal limits.
- Patient will not experience dyspnea, restlessness, or fatigue due to reduced cardiac output.
Assessment:
1. Assess for signs and symptoms associated with decreased cardiac output alongside chest pain. Monitor for indicators such as excessive sweating (diaphoresis), dyspnea, cough, nausea, vomiting, abdominal pain, fever, edema, calf pain, and lower extremity swelling, which may indicate reduced cardiac output and organ perfusion.
2. Monitor heart rate. An increase in heart rate is often an early compensatory mechanism in angina episodes as the heart attempts to maintain cardiac output.
3. Obtain ECG and review results. ECG alterations such as ST elevation, atrial fibrillation, or tachycardic rhythms are critical in guiding further treatment. Stress testing, nuclear perfusion imaging, and cardiac catheterization are valuable diagnostic tools.
4. Review lab results. Complete blood count (CBC) and basic metabolic panel (BMP) provide essential information about oxygen-carrying capacity, electrolyte balance, and kidney function, reflecting the adequacy of oxygenated blood supply to organs.
Interventions:
1. Treat the underlying cause. Identify and address the root cause of chest pain, which may be cardiac (ischemic or non-ischemic) or non-cardiac. Non-cardiac causes include lung disease, musculoskeletal issues, anxiety/panic attacks, and GERD. Cardiac causes include pericardial disease (non-ischemic) and coronary artery atherosclerosis or myocardial infarction (ischemic).
2. Implement risk factor management. Focus on managing modifiable risk factors such as blood pressure, cholesterol, and blood sugar through medication and lifestyle modifications. Patient education is key to risk reduction.
3. Encourage lifestyle modifications. Promote adherence to lifestyle changes including regular exercise, maintaining a healthy weight, and smoking cessation to reduce plaque buildup and improve blood flow.
4. Administer medications as ordered. Administer antianginal medications like nitroglycerin for immediate relief and other medications aimed at reducing myocardial oxygen demand, such as beta-blockers and calcium channel blockers (with caution in patients with low ejection fraction or left ventricular failure).
5. Control heart rate. Utilize medications like beta-blockers, ivabradine, and non-dihydropyridine calcium channel blockers to lower heart rate and reduce myocardial oxygen demand, thereby alleviating angina symptoms.
Risk for Decreased Cardiac Tissue Perfusion
Chest pain can be an indicator of cardiac conditions that heighten the risk of decreased cardiac tissue perfusion.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Heart disease/atherosclerosis.
- Hypoxia, Myocardial infarction, Ischemia, Hypoxemia.
As evidenced by:
This is a risk diagnosis, so there are no current signs and symptoms. Interventions are preventative.
Expected outcomes:
- Patient will not experience a myocardial infarction.
- Patient will report and demonstrate improvement in dyspnea, oxygen saturation, and vital signs.
Assessment:
1. Assess for symptoms and risk factors for impaired cardiac tissue perfusion. Monitor for chest pain, shortness of breath, diaphoresis, indigestion, and anxiety, which can be indicative of decreased cardiac perfusion. Identify and assess modifiable risk factors.
2. Obtain and review lab work. Monitor cardiac enzymes (troponin levels), electrolytes, and arterial blood gases (ABGs), which are crucial in assessing cardiac perfusion and oxygenation.
3. Monitor telemetry continuously. Continuously monitor blood pressure, pulse, ECG, and oxygen saturation to detect early changes indicative of decreased cardiac tissue perfusion.
Interventions:
1. Reduce cardiac workload. Administer supplemental oxygen to improve oxygenation and encourage rest or activity limitation to reduce myocardial oxygen consumption and workload.
2. Prepare for potential surgical interventions. Be prepared to assist with cardiac catheterization for visualization and stent placement or coronary artery bypass grafting (CABG) to improve cardiac tissue perfusion.
3. Administer medications as ordered. Administer vasodilators, anticoagulants, digoxin, and antihypertensives as prescribed to improve perfusion and reduce cardiac workload.
4. Educate on lifestyle modifications. Emphasize the importance of lifestyle modifications, including reducing sodium and fat intake, smoking cessation, and increasing physical activity, to improve long-term cardiac tissue perfusion.
Risk for Unstable Blood Pressure
Chest pain can be associated with either hypotension or hypertension, depending on the underlying cause.
Nursing Diagnosis: Risk for Unstable Blood Pressure
Related to:
- Ineffective cardiac muscle contraction.
- Conditions compromising blood supply (narrowed/blocked arteries, plaque rupture, vasospasm).
- Heart structure malfunctions.
- Increased cardiac workload, Dysrhythmias.
- Electrolyte imbalances, Fluid retention.
As evidenced by:
This is a risk diagnosis, so there are no current signs and symptoms. Interventions are preventative.
Expected outcomes:
- Patient will maintain blood pressure within acceptable limits.
- Patient will remain free from orthostatic changes like dizziness upon standing.
- Patient will verbalize when to contact their healthcare provider regarding hyper- or hypotension.
Assessment:
1. Routinely measure blood pressure. Regularly monitor blood pressure to detect trends and changes. Understand that in unstable angina, oxygen demand can increase even at rest, while in stable angina, it typically increases with exertion. Exercise-induced increases in heart rate, blood pressure, and myocardial contractility are primary drivers of myocardial oxygen demand.
2. Assess for subjective symptoms. Inquire about symptoms such as heart palpitations, headaches, lightheadedness, or dizziness, which may indicate episodes of hyper- or hypotension.
3. Review patient medications. Polypharmacy, especially in older adults, increases the risk of unstable blood pressure. Be aware of medications like antihypertensives, diuretics, antidepressants, and herbal remedies that can affect blood pressure.
Interventions:
1. Prevent excessive exertion. Advise patients to avoid strenuous activities that can exacerbate angina and blood pressure instability, such as heavy lifting, uphill walking, or stair climbing.
2. Educate on when to seek help for uncontrolled blood pressure. Provide clear guidelines on what blood pressure readings are considered too high or too low and when to seek immediate medical attention. Encourage regular blood pressure monitoring, especially when symptoms occur.
3. Encourage commitment to lifestyle changes. Educate patients on the significant impact of lifestyle adjustments, such as reducing sodium intake, exercising regularly, maintaining a healthy weight, limiting alcohol consumption, and quitting smoking, in managing blood pressure.
4. Strategize to improve blood pressure control. Employ strategies to enhance patient adherence to blood pressure management, including providing clear and concise instructions, simplifying medication regimens, encouraging self-monitoring, and offering comprehensive educational materials to promote overall health.
