Chest pain, clinically known as angina, is a distressing symptom that arises when the heart muscle (myocardium) doesn’t receive an adequate supply of oxygen-rich blood. It’s crucial to understand that chest pain isn’t a disease in itself but rather a significant indicator of an underlying cardiovascular issue or other medical conditions. For nurses, accurately assessing and managing chest pain is paramount to ensure timely and effective patient care. This comprehensive guide delves into the nursing diagnosis and care plan for chest pain, aiming to provide a robust understanding for healthcare professionals.
The sensation of chest pain can vary widely, described by patients as squeezing, tightness, dull ache, sharp stabbing, crushing pressure, or a burning discomfort. Severe angina may feel like an immense weight pressing down on the chest. Notably, the pain can radiate beyond the chest, extending to the neck, jaw, shoulders, arms, and even the back. Recognizing these varied presentations is vital for prompt nursing intervention and effective management.
Types of Chest Pain and Underlying Causes
Chest pain serves as a key symptom for a range of underlying medical conditions. Understanding the different types of angina and their root causes is essential for accurate nursing diagnosis and targeted care planning. These conditions include:
- Coronary Artery Disease (CAD): The most common cause of angina, CAD involves the narrowing or blockage of coronary arteries due to plaque buildup (atherosclerosis). This restricts blood flow to the heart muscle, leading to ischemic chest pain.
- Coronary Microvascular Disease (MVD): MVD affects the small coronary arteries, causing reduced blood flow and angina. This is more prevalent in women and individuals with diabetes or hypertension.
- Pleuritis: Inflammation of the lining of the lungs and chest cavity (pleura) can cause sharp chest pain that worsens with breathing or coughing.
- Pulmonary Embolism (PE): A blood clot in the pulmonary arteries can cause sudden, sharp chest pain, often accompanied by shortness of breath and other respiratory symptoms.
- Pneumothorax: Air leaking into the space between the lungs and chest wall can lead to sudden chest pain and breathing difficulties.
- Gastroesophageal Reflux Disease (GERD): Stomach acid refluxing into the esophagus can cause heartburn, which is often described as burning chest pain.
Within angina itself, there are distinct types that nurses must differentiate:
- Stable Angina (Angina Pectoris): This predictable pattern of chest pain occurs during exertion or emotional stress when the heart’s oxygen demand increases. It’s typically relieved by rest or nitroglycerin medication. Stable angina is a warning sign of CAD and requires careful management to prevent progression.
- 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) as it often results from unstable plaque rupture and partial blockage of a coronary artery. Unstable angina requires immediate medical attention.
- Variant (Prinzmetal) Angina: This type of angina is caused by coronary artery spasm, temporarily reducing blood flow to the heart. It often occurs at rest, typically between midnight and early morning, and can be triggered by cold weather, stress, or certain medications.
Risk Factors for Chest Pain
Identifying risk factors for chest pain is crucial for preventative nursing care and patient education. Many risk factors are modifiable through lifestyle changes and medical management. Key risk factors include:
- High Cholesterol (Hyperlipidemia): Elevated levels of LDL (“bad”) cholesterol contribute to plaque formation in arteries, increasing the risk of CAD and angina.
- Hypertension (High Blood Pressure): High blood pressure puts extra strain on the heart and arteries, accelerating atherosclerosis and increasing the likelihood of angina.
- Smoking: Smoking damages blood vessels, promotes plaque buildup, and reduces the oxygen-carrying capacity of blood, significantly increasing the risk of angina and heart attack.
- Overweight and Obesity: Excess weight is linked to several other risk factors like hypertension, diabetes, and high cholesterol, all contributing to heart disease and angina.
- Diabetes Mellitus: Diabetes damages blood vessels and increases the risk of atherosclerosis, making individuals with diabetes more prone to angina and other cardiovascular complications.
- Metabolic Syndrome: A cluster of conditions including high blood pressure, high blood sugar, excess abdominal fat, and abnormal cholesterol levels, metabolic syndrome significantly elevates the risk of heart disease and angina.
- Sedentary Lifestyle: Lack of physical activity contributes to obesity, hypertension, and high cholesterol, increasing the overall risk of cardiovascular disease and angina.
- Unhealthy Diet: Diets high in saturated and trans fats, cholesterol, and sodium contribute to the development of atherosclerosis and increase the risk of angina.
- Family History of Heart Disease: A family history of early heart disease increases an individual’s genetic predisposition to developing angina and related conditions.
- Age: The risk of angina increases with age, particularly for men over 45 and women over 55, as arteries naturally become less flexible and more prone to plaque buildup.
Prompt diagnosis and treatment of chest pain are essential to prevent serious complications such as myocardial infarction. Nurses play a pivotal role in initial assessment, risk factor identification, and patient education. Diagnostic tests like electrocardiograms (ECG), blood tests (including cardiac enzymes), stress tests, coronary angiography, chest X-rays, cardiac catheterization, and computed tomography angiography (CTA) are used to determine the underlying cause of chest pain and guide appropriate treatment strategies.
Nursing Process for Chest Pain Management
The nursing process is fundamental in providing structured and patient-centered care for individuals experiencing chest pain. Nurses are at the forefront of comprehensive pain assessment, which is crucial for rapid diagnosis and intervention.
The primary goals of nursing care for patients with chest pain are:
- Accurate Identification: Determine the specific type of angina and its underlying etiology.
- Immediate and Appropriate Treatment: Implement timely interventions to alleviate pain and address the root cause.
- Pain Relief and Vasodilation: Administer medications to manage pain and improve blood flow to the heart.
- Myocardial Preservation: If myocardial infarction is suspected, implement measures to minimize heart muscle damage.
- Risk Reduction through Lifestyle Modification: Educate patients on lifestyle changes to mitigate future cardiac events.
Patient education is a cornerstone of chest pain management. Nurses educate patients on recognizing the differences between stable and unstable angina, understanding their treatment plan, and knowing when to seek immediate emergency medical assistance.
Nursing Care Plans for Chest Pain
Nursing care plans are essential tools for organizing and prioritizing nursing care for patients with chest pain. They provide a framework for addressing identified nursing diagnoses and setting both short-term and long-term care goals. Here are examples of nursing care plans commonly used for chest pain:
Acute Pain
Chest pain is the defining symptom addressed in this nursing diagnosis. It’s crucial to thoroughly assess and manage the patient’s pain experience.
Nursing Diagnosis: Acute Pain
Related to:
- Myocardial injury
- Ischemia
- Disease process (e.g., CAD, MVD)
- Physical exertion
As evidenced by:
- Diaphoresis (sweating)
- Distraction behaviors (e.g., pacing, restlessness)
- Verbal reports of chest pain, pressure, tightness
- Facial grimacing or other pain expressions
- Guarding behavior (protecting the chest)
- Positioning to alleviate pain (e.g., leaning forward)
- Clutching chest
- Tachycardia (increased heart rate)
Expected Outcomes:
- Patient will report a reduction in chest pain to a tolerable level within a specified timeframe.
- Patient will identify factors that precipitate or exacerbate chest pain.
- Patient will demonstrate effective use of pain management techniques.
Assessments:
-
Assess pain characteristics: Detailed pain assessment is vital. Evaluate the onset, provoking factors, quality (sharp, dull, crushing), radiation, severity (pain scale), and timing of the pain (PQRST). This helps differentiate angina from other types of chest pain and guides appropriate interventions.
-
Review diagnostic test results: ECG findings are crucial. A 12-lead ECG is a priority for patients presenting with chest pain to rapidly detect ST-segment elevation or depression, indicating potential myocardial ischemia or infarction. Other diagnostic tests like cardiac enzyme levels further support the diagnosis.
-
Obtain history of chest pain: Determine if the patient has a history of angina or similar chest pain episodes. Comparing the current pain episode to previous experiences can help determine if this is a stable or unstable pattern and guide treatment decisions.
Interventions:
-
Administer pain medications as prescribed: Pharmacological management is key to pain relief and reducing cardiac workload. Nitrates (e.g., nitroglycerin) are commonly used for immediate angina relief due to their vasodilating effects. Analgesics may be needed for severe pain. Beta-blockers and calcium channel blockers can help manage chronic angina by reducing heart rate and contractility, thus decreasing myocardial oxygen demand.
-
Provide oxygen supplementation: Oxygen therapy increases oxygen availability to the ischemic myocardium. Administer supplemental oxygen if the patient’s oxygen saturation is below the prescribed level or as clinically indicated, even if saturation is normal, particularly in acute angina.
-
Prepare for further diagnostic testing: Non-invasive and invasive tests may be needed to determine the extent and cause of chest pain. Stress tests (exercise or pharmacological), echocardiograms, and CT angiograms help visualize coronary arteries and assess cardiac function. Prepare the patient physically and emotionally for these procedures.
-
Provide patient education on angina management: Empower patients to manage their angina effectively. Educate on recognizing angina symptoms, proper use of nitroglycerin (if prescribed), importance of rest, and when to seek emergency care (e.g., for unstable angina or pain not relieved by usual measures).
Anxiety
Chest pain, particularly when sudden and severe, can trigger significant anxiety and fear in patients. Addressing emotional distress is an integral part of nursing care.
Nursing Diagnosis: Anxiety
Related to:
- Perceived threat of death or serious illness
- Unfamiliar hospital environment and procedures
- Threat to current health status and future well-being
As evidenced by:
- Verbalization of alarm, fear, panic
- Restlessness and agitation
- Nausea
- Dry mouth
- Palpitations (awareness of rapid or irregular heartbeat)
- Difficulty concentrating
- Tachycardia
- Tachypnea (rapid breathing)
- Diaphoresis
Expected Outcomes:
- Patient will verbalize a reduction in anxiety and fear related to chest pain and its implications.
- Patient will demonstrate relaxed body language and reduced physical manifestations of anxiety.
- Patient will utilize effective coping strategies to manage anxiety.
Assessments:
- Assess patient’s feelings of fear and anxiety: Open communication is crucial. Engage in therapeutic conversation to allow the patient to express their specific thoughts and feelings about their chest pain and potential causes. Active listening and empathy can significantly reduce anxiety by validating the patient’s concerns.
Interventions:
-
Provide verbal and physical reassurance: Therapeutic presence is powerful. Offer calm and reassuring verbal communication, explaining procedures and answering questions honestly. Non-verbal reassurance, such as a gentle touch (if appropriate), can also convey support and reduce anxiety.
-
Explore and teach positive coping mechanisms: Empower patients with self-management strategies. Teach relaxation techniques like deep breathing exercises, guided imagery, or mindfulness. Distraction techniques (e.g., focusing on conversation, reading) can also be helpful. Discuss past coping strategies that have been effective for the patient.
-
Administer anti-anxiety medications as prescribed: Pharmacological intervention may be necessary in cases of severe anxiety. Benzodiazepines or other anxiolytics may be ordered to help reduce anxiety and promote relaxation. Monitor for effectiveness and side effects of medications.
-
Provide health education and knowledge: Knowledge reduces fear of the unknown. Once the acute phase of chest pain has stabilized, provide clear and simple explanations about the patient’s condition, diagnostic findings, and treatment plan. Address misconceptions and provide accurate information to foster a sense of control and reduce anxiety.
Decreased Cardiac Output
Chest pain can be a symptom of reduced 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 (e.g., due to ischemia, infarction)
- Conditions compromising blood supply (e.g., CAD, valve disorders)
- Narrowed or blocked arteries
- Coronary vasospasm
- Structural heart defects
- Impaired heart muscle function
As evidenced by:
- Increased central venous pressure (CVP)
- Tachycardia or bradycardia
- Dysrhythmias (irregular heart rhythms)
- Reduced ejection fraction (less than 40%)
- Decreased oxygen saturation (SpO2)
- Presence of abnormal heart sounds (e.g., S3, S4)
- Chest pain (angina)
- Hypotension or hypertension
- Dyspnea (shortness of breath)
- Tachypnea
- Altered mental status (e.g., confusion, restlessness)
- Fatigue, weakness
- Activity intolerance
- Cool, clammy skin
- Prolonged capillary refill time
- Edema (peripheral or pulmonary)
Expected Outcomes:
- Patient will demonstrate adequate cardiac output as evidenced by stable vital signs (heart rate, blood pressure) within patient-specific normal limits.
- Patient will maintain a normal sinus rhythm on ECG.
- Patient will exhibit improved tissue perfusion, indicated by warm and dry skin, strong peripheral pulses, and appropriate urine output.
- Patient will report reduced symptoms of decreased cardiac output, such as dyspnea and fatigue.
Assessments:
-
Assess for signs and symptoms of decreased cardiac output: Systematic assessment is crucial. Monitor for and document associated signs and symptoms beyond chest pain that indicate poor cardiac output. These include:
- Diaphoresis
- Dyspnea, orthopnea (shortness of breath when lying down)
- Cough (may be productive with pulmonary edema)
- Nausea and vomiting
- Abdominal pain (due to reduced mesenteric blood flow)
- Fatigue, weakness
- Peripheral edema (ankle, leg swelling)
- Jugular venous distention (JVD)
- Altered mental status
-
Monitor heart rate and rhythm: Heart rate is a sensitive indicator of cardiac compensation. Tachycardia is often an early sign of the heart trying to compensate for reduced output. Bradycardia or new dysrhythmias can also indicate cardiac dysfunction. Regularly assess apical and radial pulses, and continuously monitor ECG as indicated.
-
Obtain and review ECG: ECG is essential for identifying cardiac ischemia, injury, or infarction. ST-segment changes, T-wave inversions, or Q waves can indicate myocardial damage. Arrhythmias can also be detected. Serial ECGs may be needed to monitor changes over time.
-
Review laboratory results: Blood tests provide valuable information about cardiac function and overall health. Cardiac enzymes (troponin, CK-MB) are elevated in myocardial infarction. Electrolyte imbalances (potassium, sodium, magnesium) can affect cardiac rhythm and contractility. BUN and creatinine assess kidney function, which can be affected by decreased cardiac output. Complete blood count (CBC) can reveal anemia, which can exacerbate angina.
Interventions:
-
Treat the underlying cause of decreased cardiac output: Address the root problem. Identify and manage the underlying cause of chest pain and reduced cardiac output. This may involve:
- Managing non-cardiac causes (e.g., pulmonary conditions, anxiety)
- Treating non-ischemic cardiac conditions (e.g., pericarditis, myocarditis)
- Managing ischemic cardiac disease (e.g., CAD, myocardial infarction) with medications, revascularization procedures (PCI, CABG)
-
Implement risk factor management: Prevent further cardiac compromise. Aggressively manage modifiable risk factors for heart disease. Educate patients on:
- Blood pressure control
- Cholesterol management
- Blood sugar control in diabetes
- Smoking cessation
- Weight management
- Healthy diet
- Regular exercise (within cardiac limitations)
-
Encourage adherence to lifestyle modifications: Promote long-term heart health. Emphasize the importance of lifestyle changes in improving cardiac health and preventing future angina episodes and cardiac events. Provide ongoing support and resources to facilitate adherence to recommended modifications.
-
Administer medications as ordered: Pharmacological support to improve cardiac output and reduce angina. Medications may include:
- Antianginal medications (nitrates, beta-blockers, calcium channel blockers) to reduce myocardial oxygen demand and relieve angina
- ACE inhibitors or ARBs to manage hypertension and heart failure
- Diuretics to reduce fluid overload in heart failure
- Inotropes (e.g., digoxin) to increase myocardial contractility if indicated
-
Manage heart rate and rhythm: Optimize cardiac function. Control heart rate to improve cardiac output and reduce myocardial oxygen demand. Medications to manage heart rate may include:
- Beta-blockers to slow heart rate
- Calcium channel blockers (non-dihydropyridine types like verapamil, diltiazem) to slow heart rate and reduce contractility
- Antiarrhythmics to treat dysrhythmias
Risk for Decreased Cardiac Tissue Perfusion
Patients with chest pain are at risk for impaired blood flow to the heart muscle, potentially leading to myocardial infarction.
Nursing Diagnosis: Risk for Decreased Cardiac Tissue Perfusion (Ineffective Tissue Perfusion)
Related to:
- Pre-existing heart disease (CAD, atherosclerosis)
- Hypoxia
- Risk of myocardial infarction
- Ischemia
- Hypoxemia
As evidenced by: A risk diagnosis does not have “as evidenced by” criteria because the problem has not yet occurred. Interventions are focused on prevention.
Expected Outcomes:
- Patient will maintain adequate cardiac tissue perfusion as evidenced by stable vital signs, absence of chest pain, and adequate oxygen saturation.
- Patient will verbalize understanding of risk factors for decreased cardiac tissue perfusion and measures to prevent myocardial infarction.
- Patient will seek prompt medical attention for any recurrence of chest pain or related symptoms.
Assessments:
-
Assess for risk factors and symptoms of impaired cardiac tissue perfusion: Proactive risk assessment is vital. Identify patients at high risk based on their medical history, risk factors, and presenting symptoms. Assess for:
- History of angina, CAD, myocardial infarction
- Risk factors (smoking, hypertension, hyperlipidemia, diabetes, family history)
- Current chest pain characteristics
- Associated symptoms (dyspnea, diaphoresis, nausea, indigestion)
- Anxiety levels related to chest pain
-
Obtain and review laboratory work: Baseline and ongoing lab monitoring is important. Review:
- Cardiac enzymes (troponin, CK-MB) to rule out myocardial injury
- Electrolytes (potassium, magnesium, calcium) to assess for imbalances that can affect cardiac function
- Arterial blood gases (ABGs) to evaluate oxygenation and acid-base balance
- Lipid profile to assess cholesterol levels
- Blood glucose to assess for diabetes or hyperglycemia
-
Continuous telemetry monitoring: Continuous monitoring allows for rapid detection of cardiac changes. Monitor:
- Heart rate and rhythm (ECG)
- Blood pressure
- Oxygen saturation (SpO2)
- Respiratory rate
- Report any significant changes or abnormalities promptly.
Interventions:
-
Reduce cardiac workload: Minimize myocardial oxygen demand. Implement measures to reduce the heart’s workload:
- Administer supplemental oxygen to improve oxygen delivery to the heart
- Encourage bed rest or limit physical activity to reduce oxygen consumption
- Ensure a calm and restful environment to minimize stress and anxiety
- Optimize pain management to reduce the physiological stress of pain
-
Prepare for potential surgical interventions: Be ready for advanced interventions if needed. Prepare patients for possible procedures to restore coronary blood flow, such as:
- Cardiac catheterization and percutaneous coronary intervention (PCI) with stent placement to open blocked arteries
- Coronary artery bypass graft (CABG) surgery to reroute blood flow around blocked arteries
- Provide pre-procedure education and emotional support.
-
Administer medications as prescribed: Pharmacological support to improve perfusion and prevent complications. Administer medications as ordered, which may include:
- Vasodilators (e.g., nitrates) to dilate blood vessels and improve blood flow
- Anticoagulants (e.g., heparin, aspirin) to prevent blood clot formation
- Antiplatelet agents (e.g., aspirin, clopidogrel) to prevent platelet aggregation and thrombus formation
- Beta-blockers to reduce heart rate and myocardial oxygen demand
- Calcium channel blockers to reduce heart rate, contractility, and vasospasm
- Digoxin (in specific situations) to increase cardiac output
- Antihypertensives to control blood pressure
-
Educate patient on lifestyle modifications for risk reduction: Empower patients to take control of their heart health. Provide comprehensive education on:
- Heart-healthy diet (low in sodium, saturated and trans fats, cholesterol)
- Smoking cessation (provide resources and support)
- Regular physical activity (within safe limits, as advised by physician)
- Weight management
- Stress management techniques
- Medication adherence
- Importance of regular follow-up appointments
- Recognizing and responding to angina symptoms
Risk for Unstable Blood Pressure
Chest pain and underlying cardiac conditions can lead to fluctuations in blood pressure, either hypertension or hypotension, requiring careful monitoring and management.
Nursing Diagnosis: Risk for Unstable Blood Pressure
Related to:
- Ineffective myocardial contraction
- Conditions compromising blood supply (ischemia, infarction)
- Narrowed or blocked arteries
- Coronary vasospasm
- Cardiac structural malfunctions
- Increased cardiac workload
- Dysrhythmias
- Electrolyte imbalances
- Fluid volume imbalances (retention or deficit)
- Medications
As evidenced by: Risk diagnosis – no “as evidenced by” criteria. Interventions are preventative.
Expected Outcomes:
- Patient will maintain blood pressure within individually acceptable limits (systolic and diastolic).
- Patient will remain free from orthostatic hypotension (absence of dizziness or lightheadedness upon standing).
- Patient will verbalize understanding of factors that can affect blood pressure and appropriate actions to take (e.g., when to contact provider).
Assessments:
-
Routine blood pressure monitoring: Regular BP assessment is crucial. Monitor blood pressure frequently, especially during and after chest pain episodes. Note:
- Baseline blood pressure trends
- Changes in blood pressure associated with chest pain, activity, or medications
- Orthostatic blood pressures (if indicated)
- Report significant deviations from patient’s normal range.
-
Assess for subjective symptoms related to blood pressure changes: Patient reports are important indicators. Inquire about symptoms that may suggest hypo- or hypertension:
- Dizziness, lightheadedness, syncope (fainting)
- Headache, blurred vision, palpitations
- “Skipped beats” or irregular heartbeats
- Fatigue, weakness
- Nausea
-
Review medication history and current medications: Medication effects on BP are significant. Review the patient’s medication list, paying attention to:
- Antihypertensive medications (type, dosage, frequency)
- Diuretics
- Vasodilators
- Antiarrhythmics
- Antidepressants
- Herbal supplements or over-the-counter medications that could affect blood pressure
- Polypharmacy (multiple medications) and potential drug interactions
Interventions:
-
Prevent excessive exertion: Reduce triggers for angina and BP fluctuations. Advise patients to avoid activities that provoke chest pain or excessive increases in blood pressure, such as:
- Strenuous exercise
- Heavy lifting
- Climbing stairs rapidly
- Extreme temperatures
- Emotional stress
- Encourage gradual increases in activity as tolerated.
-
Educate patient on when to seek help for uncontrolled blood pressure: Empower patients to self-manage and seek timely help. Provide clear guidelines on:
- Target blood pressure ranges (individualized to patient)
- Symptoms of hypo- and hypertension to watch for
- When to self-monitor blood pressure and how often
- When to contact their healthcare provider (e.g., for persistent high or low readings, symptoms)
- Emergency contact information and when to call for immediate help (e.g., severe chest pain, dizziness with low BP)
-
Promote commitment to lifestyle changes for blood pressure control: Lifestyle modifications are fundamental for long-term BP management. Reinforce education on:
- Low-sodium diet
- DASH diet (Dietary Approaches to Stop Hypertension)
- Regular physical activity (at least 30 minutes of moderate-intensity exercise most days of the week)
- Weight management if overweight or obese
- Moderate alcohol consumption (if applicable)
- Smoking cessation
- Stress reduction techniques
-
Strategize to enhance blood pressure control adherence: Improve patient compliance with BP management. Implement strategies to promote adherence to treatment plans:
- Provide clear, concise, and easy-to-understand instructions regarding medications, lifestyle changes, and monitoring.
- Simplify medication regimens (e.g., once-daily dosing if possible) to improve convenience.
- Encourage patient participation in self-monitoring of blood pressure and recording readings.
- Provide written learning materials and resources that promote overall cardiovascular health.
- Address barriers to adherence (e.g., cost of medications, side effects, lack of understanding) and develop solutions collaboratively with the patient.
- Regularly review and reinforce the importance of blood pressure control and lifestyle modifications at follow-up appointments.
References
(References would be listed here as in the original article, ensuring proper formatting and citation style)
