Chest pain, or angina, is a significant symptom indicating that the heart muscle isn’t receiving sufficient oxygen. It’s crucial to understand that chest pain itself is not a disease but a manifestation of an underlying condition. Patients describe angina in various ways – squeezing, dull, sharp, crushing, or burning sensations. Severe chest pain can feel like immense pressure on the chest, and the pain may extend to the neck, jaw, or limbs.
This article will explore the various aspects of chest pain, focusing on its NANDA diagnoses and providing a comprehensive guide for nurses in assessing, diagnosing, and managing patients experiencing this symptom.
Types of Chest Pain and Underlying Causes
Chest pain can stem from a range of conditions, broadly categorized into cardiac and non-cardiac causes. Understanding the origin of chest pain is vital for accurate diagnosis and effective treatment. Some common underlying causes include:
- Coronary Artery Disease (CAD): The most frequent cause of angina, CAD involves the narrowing or blockage of coronary arteries due to plaque buildup, reducing blood flow to the heart.
- Coronary Microvascular Disease (MVD): This condition affects the small blood vessels of the heart, leading to angina, particularly in women.
- Pleuritis: Inflammation of the lining of the lungs and chest cavity, causing sharp chest pain that worsens with breathing.
- Pulmonary Embolism (PE): A blood clot in the lung arteries, which can cause sudden, sharp chest pain, shortness of breath, and other serious symptoms.
- Pneumothorax: Collapsed lung, which can result in sudden chest pain and breathing difficulty.
- Gastroesophageal Reflux Disease (GERD): Stomach acid refluxing into the esophagus can cause heartburn and chest pain that mimics angina.
Angina itself is further classified into different types, each with distinct characteristics:
- Stable Angina (Angina Pectoris): The most common type, stable angina is usually triggered by physical exertion or emotional stress. The pain is predictable, often described as pressure or squeezing, and typically relieved by rest or nitroglycerin medication. It occurs when the heart’s oxygen demand exceeds supply due to narrowed arteries from CAD.
- Unstable Angina: This is a more serious form of angina characterized by unexpected chest pain that can occur even at rest. It signifies a higher risk of myocardial infarction (heart attack) and requires immediate medical attention. Unstable angina often arises from the rupture of plaque in a coronary artery, leading to a sudden reduction in blood flow.
- Variant (Prinzmetal) Angina: This type of angina is caused by a spasm in the coronary arteries, temporarily narrowing them and reducing blood flow. Variant angina often occurs at rest, typically between midnight and early morning, and can be triggered by cold weather, stress, smoking, or certain medications.
Risk Factors for Chest Pain
Several risk factors increase the likelihood of developing conditions that cause chest pain. Identifying these risk factors is crucial for preventative measures and patient education. Major risk factors include:
- High Cholesterol: Elevated levels of LDL (“bad”) cholesterol contribute to plaque formation in arteries.
- Hypertension (High Blood Pressure): High blood pressure strains the heart and arteries, accelerating the development of CAD.
- Smoking: Smoking damages blood vessels, increases blood pressure, and reduces oxygen supply to the heart.
- Overweight or Obesity: Excess weight puts extra strain on the heart and increases the risk of other conditions like diabetes and hypertension.
- Diabetes Mellitus: Diabetes increases the risk of heart disease by damaging blood vessels and nerves.
- Metabolic Syndrome: A cluster of conditions including high blood pressure, high blood sugar, unhealthy cholesterol levels, and abdominal fat, significantly increasing heart disease risk.
- Sedentary Lifestyle: Lack of physical activity contributes to obesity, high cholesterol, and hypertension.
- Unhealthy Diet: Diets high in saturated and trans fats, cholesterol, and sodium increase the risk of heart disease.
- Family History of Heart Disease: Genetic predisposition plays a role in heart disease risk.
- Older Age: The risk of heart disease increases with age, particularly for men over 45 and women over 55.
Prompt diagnosis and treatment of chest pain are essential to prevent severe complications like myocardial infarction. A thorough physical assessment and identification of risk factors are the first steps. Diagnostic tests, including electrocardiograms (ECG), blood tests, stress tests, coronary angiography, chest X-rays, cardiac catheterization, and computed tomography angiography (CTA), are used to confirm the underlying cause of chest pain and guide appropriate treatment.
Nursing Process and Chest Pain Management
Nurses play a critical role in the comprehensive assessment and management of patients presenting with chest pain. A thorough pain assessment is paramount to facilitate timely diagnosis and intervention.
The primary goals of treatment for patients experiencing chest pain are:
- Accurate identification of the type of angina and its underlying cause.
- Prompt and appropriate treatment to alleviate pain and address the root cause.
- Medications for pain relief and vasodilation to improve blood flow.
- Preservation of heart muscle if myocardial infarction is suspected.
- Lifestyle modifications to mitigate future risks and improve long-term health.
Patient education is a cornerstone of nursing care. It includes teaching patients how to differentiate between stable and unstable angina, understanding their treatment plan, and knowing when to seek immediate emergency assistance.
Nursing Care Plans and NANDA Diagnoses for Chest Pain
Once a nurse has assessed a patient with chest pain, formulating appropriate nursing diagnoses is crucial. NANDA International (NANDA-I) diagnoses provide a standardized language for nurses to identify patient problems and guide care planning. Nursing care plans based on these diagnoses help prioritize assessments and interventions to achieve both short-term and long-term patient goals.
Here are examples of common NANDA nursing diagnoses relevant to chest pain:
Acute Pain
Chest pain, regardless of its specific description, is fundamentally an experience of acute pain.
Nursing Diagnosis: Acute Pain
Related To:
- Myocardial injury
- Ischemia
- Disease process (e.g., CAD, PE, GERD)
- Physical exertion
As Evidenced By:
- Diaphoresis (sweating)
- Distraction behavior (e.g., pacing, restlessness)
- Verbal and nonverbal expressions of chest pain/pressure/tightness
- Facial grimacing or expressions of pain
- Guarding behavior
- Assuming positions to alleviate pain
- Clutching the chest
- Tachycardia (increased heart rate)
Expected Outcomes:
- The patient will report a reduction in chest pain to a tolerable level within a specified timeframe.
- The patient will identify factors that exacerbate or relieve their chest pain.
- The patient will demonstrate effective pain management strategies.
Nursing Assessments:
- Assess pain characteristics: Utilize a pain assessment tool (e.g., PQRST) to thoroughly evaluate the pain’s provocation, quality, radiation, severity, and timing. Determine when the pain started, precipitating factors, pain characteristics (sharp, dull, squeezing), duration, and location. This detailed assessment is essential for accurate diagnosis and tailored management.
- Review diagnostic test results: Pay close attention to the results of diagnostic tests, particularly a 12-lead ECG, which is frequently performed immediately for patients with chest pain to rule out or confirm myocardial infarction.
- Elicit history of chest pain: Inquire about any prior episodes of chest pain. Determining if the current pain is similar to previous episodes can provide valuable clues for diagnosis and treatment planning.
Nursing Interventions:
- Administer pain medications as prescribed: Provide analgesics as ordered, which may include nitrates, morphine, or other pain relievers, based on the severity and type of chest pain and the physician’s orders. Drug therapy aims to alleviate pain and reduce the risk of myocardial infarction and death. Medications like short-acting nitrates, ACE inhibitors, analgesics, and calcium channel blockers may be administered to improve myocardial perfusion.
- Administer supplemental oxygen if indicated: Provide oxygen therapy to increase myocardial oxygenation, especially if the patient is hypoxic or has decreased oxygen saturation levels. Oxygen supplementation may not be necessary if oxygen saturation is within the normal range.
- Prepare the patient for further diagnostic testing: Prepare the patient for stress tests, echocardiograms, CTAs, or other procedures as ordered to further evaluate the cause of chest pain. These tests help visualize coronary arteries and identify blockages, guiding further treatment decisions.
- Provide comprehensive patient education: Educate the patient about recognizing and managing stable angina, including proper administration of nitroglycerin tablets and when to seek emergency medical attention. Ensure the patient understands their medication regimen, lifestyle modifications, and warning signs to watch for.
Anxiety
The experience of chest pain can be frightening and trigger significant anxiety in patients.
Nursing Diagnosis: Anxiety
Related To:
- Perceived threat of death or serious illness
- Unfamiliar healthcare environment and procedures
- Potential changes in health status and lifestyle
As Evidenced By:
- Verbalization of alarm, fear, or panic
- Restlessness and agitation
- Nausea
- Dry mouth
- Palpitations (awareness of rapid or irregular heartbeat)
- Difficulty concentrating
- Tachycardia (increased heart rate)
- Tachypnea (rapid breathing)
- Diaphoresis (sweating)
Expected Outcomes:
- The patient will verbalize a reduction in anxiety and fear related to their chest pain experience.
- The patient will demonstrate effective coping mechanisms to manage anxiety.
- The patient will report feeling a sense of safety and decreased fear.
Nursing Assessments:
- Assess the patient’s feelings of fear and anxiety: Engage in open communication with the patient to understand their specific thoughts and feelings about their chest pain and the situation. Discuss their perceptions of threat, fears about their health, and any anxieties related to the healthcare environment. Addressing the patient’s expressed concerns can help alleviate unnecessary fear and anxiety.
Nursing Interventions:
- Provide verbal and physical reassurance: Offer consistent verbal and physical reassurance to promote a sense of safety and security. Provide emotional support while the patient expresses their fears and emotions. Simple gestures like calmly rubbing the patient’s back or holding their hand can offer significant physical and emotional support.
- Explore positive coping mechanisms: Discuss and encourage the use of positive coping strategies to manage anxiety. Teach the patient relaxation techniques such as deep breathing exercises, guided imagery, or mindfulness. Chest pain, dyspnea, and other symptoms can be highly alarming; equipping patients with self-calming strategies is crucial.
- Administer anti-anxiety medications if prescribed: If anxiety is severe and non-pharmacological interventions are insufficient, administer anti-anxiety medications as prescribed by the physician. Benzodiazepines or other anxiolytics may be necessary to promote relaxation and reduce overwhelming fear and anxiety, especially in acute situations.
- Provide patient education and knowledge: Address knowledge deficits by providing clear and accurate information about the patient’s condition, chest pain, symptoms, and treatment plan. Once the acute threat has subsided, discuss the nature of their chest pain, potential triggers, management strategies, and prognosis. Empowering patients with knowledge about their health promotes a sense of control and reduces fear and anxiety.
Decreased Cardiac Output
Chest pain can be a symptom of decreased cardiac output, where the heart is not pumping enough blood to meet the body’s needs.
Nursing Diagnosis: Decreased Cardiac Output
Related To:
- Ineffective myocardial contraction
- Conditions compromising blood supply to the heart
- Narrowed or blocked arteries (CAD)
- Rupture of unstable plaque
- Coronary vasospasm
- Structural heart defects
- Impaired myocardial pumping ability
As Evidenced By:
- Changes in hemodynamic parameters (e.g., decreased ejection fraction <40%)
- Increased central venous pressure (CVP)
- Tachycardia, bradycardia, or dysrhythmias
- Decreased oxygen saturation (SpO2)
- Abnormal heart sounds (e.g., S3, S4)
- Chest pain (angina)
- Hypotension or hypertension
- Dyspnea (shortness of breath) or tachypnea (rapid breathing)
- Changes in level of consciousness, restlessness, or confusion
- Fatigue and activity intolerance
- Peripheral vasoconstriction (cold, clammy skin)
- Prolonged capillary refill time
- Peripheral edema
Expected Outcomes:
- The patient will demonstrate adequate cardiac output as evidenced by stable vital signs, including heart rate and blood pressure within acceptable limits.
- The patient will maintain a normal sinus rhythm on ECG.
- The patient will report reduced or absent symptoms of decreased cardiac output, such as dyspnea, fatigue, and restlessness.
- The patient will demonstrate hemodynamic stability.
Nursing Assessments:
-
Assess for signs and symptoms of decreased cardiac output: Systematically assess for signs and symptoms that may accompany chest pain and indicate reduced cardiac output and tissue perfusion. These may include:
- Diaphoresis (excessive sweating)
- Dyspnea (shortness of breath)
- Cough
- Nausea and vomiting
- Abdominal pain
- Fever
- Edema (swelling)
- Calf pain (potential DVT)
- Swelling in the lower extremities
-
Monitor heart rate and rhythm: Continuously monitor heart rate and rhythm. Tachycardia is often an initial compensatory mechanism in angina as the heart attempts to increase cardiac output. Note any irregularities or dysrhythmias.
-
Obtain and interpret ECG: Obtain a 12-lead ECG and monitor for any changes, such as ST-segment elevation or depression, T-wave inversions, or arrhythmias, which may indicate myocardial ischemia or injury. Exercise or medication stress testing, nuclear perfusion imaging, and diagnostic cardiac catheterization may be necessary for further evaluation. ECG alterations like ST elevation, atrial fibrillation, or tachycardic rhythms guide further treatment strategies.
-
Review laboratory results: Review relevant laboratory results, including complete blood count (CBC) and basic metabolic panel (BMP). CBC can identify conditions like anemia or infection that can affect oxygen delivery. BMP assesses electrolyte balance and kidney function, both crucial for cardiac health. These tests provide insights into the adequacy of oxygenated blood supply to organs.
Nursing Interventions:
-
Treat the underlying cause of decreased cardiac output: Identify and address the underlying etiology of chest pain and decreased cardiac output. Recognize that chest pain can arise from cardiac (ischemic and non-ischemic) and non-cardiac factors, all leading to an imbalance between myocardial oxygen supply and demand.
- Non-cardiac causes include pulmonary disease, musculoskeletal issues, anxiety/panic disorders, and GERD.
- Non-ischemic cardiac causes may include pericardial disease.
- Ischemic cardiac conditions, such as coronary artery atherosclerosis and myocardial infarction, are common causes of cardiac ischemia.
-
Implement risk factor management: Actively manage modifiable risk factors for heart disease. Focus on controlling blood pressure, cholesterol levels, and blood glucose. Educate patients on medication adherence and the importance of lifestyle modifications to reduce individual risk profiles.
-
Encourage lifestyle modifications: Promote and support patient adherence to recommended lifestyle modifications. Emphasize that lifestyle changes reduce further plaque buildup in arteries and minimize blood vessel damage, thereby maintaining optimal blood flow. Educate on regular exercise, maintaining a healthy weight, smoking cessation, and adopting a heart-healthy diet.
-
Administer medications as prescribed: Administer medications as ordered to improve cardiac output and relieve chest pain. Antianginal medications, such as nitroglycerin, provide immediate relief of angina. The overall goal of symptomatic control is to reduce myocardial oxygen demand and improve cardiac function.
-
Manage heart rate: Implement strategies to control heart rate within the desired range. Certain angina medications, including beta-blockers, ivabradine, and non-dihydropyridine calcium channel blockers, reduce symptoms by decreasing heart rate. Note contraindications; for instance, calcium channel blockers should be avoided in patients with low ejection fraction and left ventricular failure.
Risk for Decreased Cardiac Tissue Perfusion
Chest pain itself signifies a potential risk for inadequate blood flow to the heart muscle.
Nursing Diagnosis: Risk for Ineffective Tissue Perfusion (Cardiac)
Related To:
- Underlying heart disease or atherosclerosis
- Hypoxia
- Myocardial infarction
- Ischemia
- Hypoxemia
As Evidenced By:
- A risk diagnosis is not evidenced by actual signs and symptoms but by the presence of risk factors. In this case, the presence of chest pain and associated risk factors for heart disease indicate the potential for decreased cardiac tissue perfusion.
Expected Outcomes:
- The patient will maintain adequate cardiac tissue perfusion, as evidenced by stable vital signs, absence of chest pain, and appropriate ECG findings.
- The patient will report and demonstrate improvement in symptoms such as dyspnea, and maintain adequate oxygen saturation levels.
- The patient will not experience a myocardial infarction.
Nursing Assessments:
- Assess for risk factors and symptoms of impaired cardiac tissue perfusion: Continuously assess for risk factors for decreased cardiac tissue perfusion and monitor for any new or worsening symptoms, such as chest pain, shortness of breath, diaphoresis, unexplained indigestion, and associated anxiety, which can be indicative of reduced cardiac perfusion.
- Review laboratory results: Monitor cardiac enzyme levels, particularly troponin, as well as electrolytes and arterial blood gases (ABGs). Elevated troponin levels indicate myocardial damage. Electrolyte imbalances and abnormal ABGs can further compromise cardiac function and oxygenation.
- Continuous telemetry monitoring: Implement continuous monitoring of vital signs, including blood pressure, heart rate, ECG, and oxygen saturation (SpO2). Closely observe for any changes or trends that may indicate compromised cardiac tissue perfusion.
Nursing Interventions:
- Reduce cardiac workload: Implement measures to reduce cardiac workload and oxygen demand. Administer supplemental oxygen to enhance oxygenation. Encourage bed rest or activity restriction to minimize oxygen consumption and reduce cardiac strain.
- Prepare for potential surgical interventions: Prepare the patient for potential surgical or interventional procedures as indicated. Cardiac catheterization may be needed to visualize and treat narrowed or blocked coronary arteries, potentially including stent placement. Coronary artery bypass grafting (CABG) might be necessary to reroute blood flow around significant blockages in severe cases.
- Administer medications as prescribed: Administer prescribed medications to improve cardiac perfusion and reduce workload. Vasodilators, such as nitrates, relax blood vessels and improve blood flow. Anticoagulants may be used to prevent clot formation. Digoxin can enhance cardiac contractility and output. Antihypertensive medications help manage blood pressure and reduce strain on the heart.
- Educate on lifestyle modifications for long-term management: Provide comprehensive education on lifestyle modifications to manage underlying risk factors and prevent future cardiac events. Emphasize the importance of reducing sodium and fat intake, smoking cessation, increasing physical activity, and adhering to a heart-healthy diet.
Risk for Unstable Blood Pressure
Chest pain can be associated with fluctuations in blood pressure, either hypotension or hypertension, depending on the underlying cause and the body’s response.
Nursing Diagnosis: Risk for Unstable Blood Pressure
Related To:
- Ineffective cardiac muscle contraction
- Conditions that compromise cardiac blood supply
- Narrowed or blocked arteries
- Rupture of unstable plaque
- Coronary vasospasm
- Structural heart defects
- Increased cardiac workload
- Dysrhythmias
- Electrolyte imbalances
- Fluid volume imbalances
As Evidenced By:
- Risk diagnosis, evidenced by risk factors, not current signs or symptoms. The presence of chest pain and associated cardiac risk factors indicates a heightened risk for blood pressure instability.
Expected Outcomes:
- The patient will maintain blood pressure within individually acceptable limits.
- The patient will remain free from orthostatic hypotension and related symptoms such as dizziness upon standing.
- The patient will verbalize understanding of when to contact their healthcare provider regarding hypo- or hypertension.
Nursing Assessments:
- Routine blood pressure monitoring: Monitor the patient’s blood pressure frequently and routinely, noting trends and significant fluctuations. 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 major determinants of myocardial oxygen demand.
- Assess for subjective symptoms: Inquire about subjective symptoms that may indicate blood pressure instability, such as palpitations, headaches, lightheadedness, dizziness, or syncope. These symptoms can be associated with both hypertension and hypotension.
- Medication review: Conduct a thorough medication review, paying particular attention to polypharmacy, especially in older adults. Be aware that multiple antihypertensive medications, diuretics, antidepressants, and even herbal remedies can interact and significantly affect blood pressure control.
Nursing Interventions:
- Prevent excessive physical exertion: Advise the patient to avoid activities that could provoke angina or blood pressure instability. Explain that activities like strenuous exercise, walking uphill, or climbing stairs can trigger chest pain (pressure, squeezing, soreness, or fullness) in patients with blood pressure issues.
- Educate on when to seek help for blood pressure issues: Educate the patient about blood pressure parameters that warrant medical attention. Because patients may not know what constitutes “too high” or “too low” blood pressure, provide clear guidelines. Encourage regular blood pressure monitoring, especially when symptoms occur. Advise them on specific blood pressure readings that require immediate contact with their healthcare provider.
- Promote lifestyle modifications for blood pressure management: Emphasize the importance of lifestyle modifications in managing blood pressure. Explain that simple changes can significantly lower blood pressure (by 10-20 mmHg or more). These include reducing sodium intake, regular physical activity, maintaining a healthy weight, limiting alcohol consumption, and smoking cessation.
- Strategize to enhance blood pressure control and adherence: As nurses play a crucial role in blood pressure management, implement strategies to improve patient adherence to treatment plans. Effective strategies include:
- Providing clear, concise, and logical instructions in easily understandable language.
- Simplifying medication regimens, ideally to once-daily dosing, when possible.
- Encouraging patient participation through self-monitoring of blood pressure.
- Providing accessible learning materials and resources that promote overall cardiovascular health and blood pressure management.
By utilizing these NANDA diagnoses and implementing tailored nursing care plans, nurses can effectively manage patients experiencing chest pain, address their underlying needs, and improve patient outcomes. This comprehensive approach ensures that both the physical and emotional aspects of chest pain are addressed, leading to better patient care and health management.
References
(References from the original article are assumed to be valid and relevant and thus are implicitly included. For a real-world scenario, these should be verified and potentially expanded upon with more recent and authoritative sources.)
