Chest Pain Nursing Diagnosis: Comprehensive Guide for Nurses

Chest pain, or angina pectoris, is a common symptom indicative of myocardial ischemia, often stemming from coronary artery disease (CAD). It’s crucial for nurses to understand the nuances of chest pain, its underlying causes, and effective nursing interventions to provide optimal patient care. This guide will delve into the nursing diagnosis of chest pain, building upon the foundational knowledge provided by Nurseslabs, and expanding to offer a more comprehensive understanding tailored for nurses in English-speaking healthcare environments.

Understanding Chest Pain (Angina Pectoris)

Angina pectoris, commonly known as chest pain, isn’t a disease itself, but rather a symptom of an underlying cardiac issue, most frequently coronary artery disease (CAD). This condition arises when the coronary arteries, responsible for supplying oxygen-rich blood to the heart muscle, become narrowed or blocked. This obstruction, often due to plaque buildup or arterial spasms, reduces blood flow to the myocardium, leading to myocardial ischemia. The resulting oxygen deficit triggers the sensation of chest discomfort, pressure, or pain.

Chest pain associated with angina can manifest in various locations, including the chest, neck, arms, or back. However, patients typically describe it as a pain or pressure sensation located behind the sternum. This pain often radiates down the left arm, but it can also extend to both arms, the back, shoulder, jaw, or neck.

Types of Angina

Angina is categorized into three primary types, each with distinct characteristics:

Stable Angina: This type of chest pain is predictable and typically occurs during physical exertion or emotional stress. It’s associated with stable plaque accumulation in the coronary arteries. The pain is usually relieved by rest or medication like nitroglycerin.
Variant (Prinzmetal’s) Angina: A less frequent form, variant angina is characterized by chest pain episodes that occur at rest, often at night or early morning. Unlike stable and unstable angina, it’s caused by coronary artery vasospasms, leading to a temporary reduction in blood flow and transient ST-segment elevation on an electrocardiogram (ECG).
Unstable Angina: This is a more concerning form of angina, characterized by chest pain that occurs with increasing frequency, severity, and unpredictability. It can happen at rest or with minimal exertion and may not be fully relieved by rest or usual medications. Unstable angina is a warning sign that a heart attack may be imminent and requires immediate medical attention.

Coronary artery disease (CAD) is a leading cause of chest pain. CAD involves the buildup of plaque inside the coronary arteries. This plaque, composed of fat, cholesterol, calcium, and other blood components, narrows the arteries, restricting blood flow to the heart muscle. Plaque can also rupture, leading to blood clot formation, which can further obstruct blood flow, potentially causing a heart attack (myocardial infarction). When oxygen-rich blood cannot reach the heart muscle due to narrowed or blocked arteries, it results in angina. If left untreated, a heart attack can lead to severe complications and even death.

For a deeper understanding of the pathophysiology and medical management of angina pectoris, refer to comprehensive resources on Angina Pectoris.

Nursing Care Plan and Management for Chest Pain

Nursing care for patients experiencing chest pain focuses on rapid assessment, effective pain management, and vigilant monitoring of vital signs. This ensures timely interventions and promotes patient well-being. This section will explore the nursing care management strategies for patients with angina pectoris (chest pain).

Prioritized Nursing Problems

The primary nursing priorities for patients presenting with chest pain are:

Pain Management: Alleviating acute chest pain and discomfort.
Cardiac Monitoring: Ensuring adequate cardiac output and preventing complications.
Patient Education: Providing knowledge about their condition, treatment, and lifestyle modifications.
Anxiety Reduction: Offering emotional support and managing anxiety related to chest pain.

Nursing Assessment for Chest Pain

A thorough nursing assessment is crucial for patients experiencing chest pain. It helps identify the underlying cause, evaluate symptom severity, and guide appropriate interventions for optimal patient outcomes.

Subjective and Objective Data to Assess:

Pain Characteristics: Detailed reports of pain, including frequency, duration, intensity, location, and aggravating/relieving factors. Note any changes in pain patterns, especially worsening pain.
Patient Behavior: Observe for narrowed focus, distraction behaviors (moaning, crying, restlessness, guarding), and anxiety reports.
Autonomic Responses: Monitor for diaphoresis, changes in blood pressure and pulse rate, pupillary dilation, and alterations in respiratory rate.
Emotional State: Assess for situational crisis, anxiety, and fear related to chest pain.

Factors Related to Chest Pain:

Decreased Myocardial Blood Flow: Conditions reducing coronary blood supply.
Increased Cardiac Workload and Oxygen Consumption: Factors increasing heart’s oxygen demand.
Myocardial Tissue Ischemia: Evidence of oxygen deprivation to the heart muscle.

Patient experiencing chest pain being assessed by a nurse

Nursing Diagnosis for Chest Pain

Based on a comprehensive assessment, a nursing diagnosis is formulated to address the specific challenges associated with chest pain (angina). While nursing diagnoses provide a framework for care, clinical judgment remains paramount in tailoring care plans to individual patient needs and priorities.

Common Nursing Diagnoses related to Chest Pain:

Acute Pain related to myocardial ischemia as evidenced by patient reports of chest pain, changes in vital signs, and restlessness.
Decreased Cardiac Output related to altered contractility secondary to myocardial ischemia as evidenced by changes in blood pressure, heart rate, and rhythm.
Anxiety related to chest pain and fear of cardiac event as evidenced by patient reports of anxiety, restlessness, and changes in vital signs.
Deficient Knowledge related to angina, management, and lifestyle modifications as evidenced by patient questions and expressed lack of understanding.
Activity Intolerance related to imbalance between oxygen supply and demand as evidenced by reports of fatigue and chest pain with exertion.

Nursing Goals and Expected Outcomes

The goals and expected outcomes for a patient with chest pain should include:

Pain Management: The patient will report a decrease in the frequency, duration, and severity of anginal episodes.
Pain Relief: The patient will demonstrate relief of chest pain as evidenced by stable vital signs, absence of muscle tension and restlessness, and verbal reports of pain reduction.
Understanding of Condition: The patient will verbalize understanding of their disease process, therapeutic regimen, management strategies, and potential complications.
Lifestyle Modifications: The patient will initiate necessary lifestyle changes to prevent potential myocardial complications associated with chest pain.

Nursing Interventions and Actions for Chest Pain

Nursing interventions for chest pain (angina pectoris) are focused on managing acute pain, administering medications, reducing oxygen demand, preventing complications, providing emotional support, and educating patients for long-term management.

1. Managing Acute Chest Pain and Discomfort

Angina pectoris results from myocardial ischemia due to reduced blood flow to the heart muscle. Nursing interventions aim to alleviate pain and discomfort by addressing the underlying ischemia.

Nursing Interventions:

Perform a comprehensive pain assessment: Determine the onset, provoking factors, quality, region, radiation, severity, and timing (OPQRST) of the chest pain. This helps differentiate angina from other causes of chest pain and assess for progression to unstable angina. Changes from stable to unstable angina can be life-threatening and require immediate attention.
Assess and document the patient’s response to medications: Monitor the effectiveness of pain medications and note any adverse effects. This information helps evaluate disease progression and adjust the therapeutic regimen as needed. Microvascular spasms may not respond to short-acting nitrates, requiring different treatment strategies.
Monitor vital signs frequently: Assess vital signs every five minutes during an initial anginal attack. Tachycardia, bradycardia, hypertension, or hypotension can occur. Hypotension is a serious sign indicating hemodynamic compromise and a predictor of poor outcomes.
Auscultate heart sounds: Monitor heart rate and rhythm. Irregular heart rhythms, S3 or S4 gallops, and new heart murmurs can indicate complications or worsening cardiac function.
Elevate the head of the bed: Position the patient with the head of the bed elevated, especially if they are short of breath or receiving nitrates. This promotes gas exchange and reduces shortness of breath. During angina episodes, maintain the head of the bed at no more than 30 degrees to prevent hypotension and headache, common side effects of some medications and positions.
Encourage prompt reporting of pain: Instruct the patient to immediately report any chest pain to allow for timely medication administration. Prompt intervention can reduce myocardial workload and prevent cardiac complications. Angina typically subsides with rest or nitrates, while unstable angina may not be relieved by these measures.
Monitor medication effects and adverse reactions: Document blood pressure, heart rate, and rhythm before and after medication administration. The goal of medications is to reduce myocardial oxygen demand. Be aware of potential adverse effects, such as hypotension from nitrates or negative inotropic effects from beta-blockers.

2. Administering Medications and Pharmacologic Interventions

Nurses play a vital role in medication management for chest pain, ensuring accurate administration, monitoring patient responses, and providing essential patient education.

Medications Commonly Used for Chest Pain:

Nitrates (Nitroglycerin, Isosorbide): Administer sublingual, buccal, oral tablets, or metered-dose sprays as prescribed. Nitroglycerin is the standard treatment for acute angina, dilating coronary arteries and reducing pain. Monitor for hypotension and headache post-administration. Long-acting nitrates prevent recurrent angina by reducing vasospasms and cardiac workload.
Beta-blockers (Metoprolol, Atenolol, Propranolol): Administer beta-blockers as prescribed to reduce heart rate and myocardial contractility, thereby decreasing oxygen demand. These are often effective for stable angina. Monitor heart rate and blood pressure.
Calcium Channel Blockers (Amlodipine, Diltiazem, Nifedipine): Administer calcium channel blockers to relax coronary vascular smooth muscle, dilate coronary arteries, and reduce peripheral vascular resistance. These agents improve myocardial oxygen delivery and reduce cardiac workload.
Analgesics (Morphine Sulfate): Administer morphine intravenously for severe angina pain, particularly pre-infarction angina. Morphine relieves pain and reduces anxiety. Monitor for respiratory depression and hypotension.
Lipid-Lowering Agents (Statins, Bile Acid Sequestrants): Administer lipid-lowering agents as prescribed to manage underlying hyperlipidemia and reduce plaque buildup in coronary arteries. These medications are crucial for long-term management and prevention of cardiac events.
Antiplatelet Agents (Aspirin, Clopidogrel): Administer antiplatelet agents to reduce platelet aggregation and prevent blood clot formation, especially in unstable angina. Aspirin is often recommended for daily use.
Anticoagulants (Heparin): Administer intravenous heparin for unstable angina to reduce the risk of myocardial infarction by preventing thrombotic complications. Low-molecular-weight heparin (LMWH) is increasingly used due to its predictable effects and reduced bleeding risk.

3. Decreasing Oxygen Demand and Managing Decreased Cardiac Output

Reducing myocardial oxygen demand and optimizing cardiac output are crucial for managing angina. Interventions focus on improving oxygen supply and reducing the heart’s workload.

Therapeutic Nursing Interventions:

Administer supplemental oxygen: Provide oxygen therapy as indicated to increase oxygen availability to the myocardium and reverse ischemia. Hypoxia is common in angina due to decreased perfusion.
Monitor for associated symptoms: Observe for dyspnea, nausea, vomiting, dizziness, palpitations, and the urge to urinate. These symptoms can indicate decreased cardiac output and autonomic nervous system responses to ischemia.
Provide cardiac-friendly meals: Offer light meals low in saturated fats, cholesterol, sodium, and refined sugars. Encourage rest for one hour after meals to reduce myocardial workload associated with digestion.
Continuously monitor vital signs and cardiac rhythm: Assess for tachycardia, bradycardia, hypertension, hypotension, and dysrhythmias. ECG monitoring is essential to detect changes indicating ischemia or dysrhythmias.
Auscultate breath and heart sounds: Listen for S3, S4 heart sounds, crackles in the lungs, and new murmurs, which can indicate cardiac decompensation or valvular issues.
Assess skin color and peripheral pulses: Evaluate peripheral circulation for signs of decreased cardiac output, such as pallor, cyanosis, and diminished pulses.
Monitor pulse oximetry or ABGs: Maintain oxygen saturation above 95% unless the patient has COPD.
Monitor laboratory studies: Pay close attention to PTT and aPTT if the patient is on heparin therapy to ensure therapeutic anticoagulation levels.
Measure cardiac output and functional parameters: Use non-invasive methods like thoracic electrical bioimpedance (TEB) to assess cardiac index, preload, afterload, and contractility to evaluate response to therapy.
Ensure complete rest during anginal episodes: Reduce myocardial oxygen demand during pain episodes to minimize tissue injury.
Maintain bed or chair rest: Encourage bed or chair rest in a comfortable position during acute episodes. Patients with unstable angina require hospital admission and continuous telemetry monitoring.
Promote adequate rest periods: Encourage rest between activities and assist with self-care activities to conserve energy and reduce cardiac workload.
Educate on avoiding Valsalva maneuver: Instruct patients to avoid straining during bowel movements and breath-holding, as these can negatively impact cardiac output.
Administer supplemental oxygen as needed: Provide oxygen to improve myocardial oxygenation and reduce pain.
Prepare for stress testing and cardiac catheterization: Explain the purpose and prepare patients for diagnostic procedures like stress testing and cardiac catheterization to assess cardiac function and coronary artery disease severity.

4. Monitoring and Preventing Potential Myocardial Complications

Preventing myocardial complications is a priority in chest pain management. Early recognition and intervention are crucial.

Interventions for Preventing Myocardial Complications:

Evaluate pain radiation: Assess for pain radiating to the jaw, neck, shoulder, arm, or hand, especially on the left side, as this can indicate cardiac pain.
Monitor serial ECG changes: Assess for ST-segment depression or elevation and T-wave inversion, which indicate myocardial ischemia. Serial ECGs help track changes and provide a baseline for comparison.
Instruct patient to immediately report chest pain: Emphasize the importance of promptly reporting any chest pain, pressure, or heaviness. Early reporting allows for timely intervention and prevents potential complications.
Assess for heart failure signs and symptoms: Monitor for signs of heart failure, such as shortness of breath, edema, and fatigue, as angina can be a symptom of underlying cardiac dysfunction leading to heart failure.
Administer antianginal medications promptly: Provide medications as prescribed to manage angina and reduce the risk of myocardial infarction.
Closely monitor cardiac rhythm: Be vigilant for silent ischemia, where ECG changes indicate ischemia without reported chest pain.
Prepare for surgical interventions: Prepare patients for potential interventions like angioplasty, stent placement, valve replacement, or CABG if indicated based on the severity of CAD and myocardial ischemia.
Prepare for critical care transfer: Transfer patients to a critical care unit if they experience prolonged chest pain with decreased cardiac output or other signs of complications.

5. Providing Emotional Support and Reducing Anxiety

Chest pain can be frightening and anxiety-provoking. Providing emotional support is an integral part of nursing care.

Interventions for Emotional Support and Anxiety Reduction:

Maintain a calm environment: Stay with the patient during pain episodes and create a calm atmosphere. Anxiety exacerbates myocardial workload and pain. The nurse’s presence can reduce fear and helplessness.
Assess patient and family understanding: Evaluate their understanding of the diagnosis, treatment plan, and lifestyle changes. Tailor education to their level of understanding and address concerns.
Observe physical responses to anxiety: Monitor for restlessness, vital sign changes, and repetitive movements, which can indicate anxiety levels.
Identify coping mechanisms: Identify previous successful coping strategies and current strengths to build on.
Explain tests and procedures: Provide clear explanations about stress testing, cardiac catheterization, and other procedures to reduce anxiety related to the unknown.
Encourage expression of feelings: Create a safe space for patients and families to express their feelings and fears. Verbalizing concerns can reduce tension and facilitate coping.
Answer questions honestly: Provide honest and accurate answers to questions to build trust and address misinterpretations.
Encourage normal social interaction: Encourage family and friends to treat the patient normally to reassure them that their role in life is not diminished.
Reassure about medical regimen efficacy: Explain that the treatment plan is designed to control symptoms and improve cardiac stability.
Promote stress reduction techniques: Introduce relaxation techniques, music therapy, or other stress-reducing activities.
Involve patient in decision-making: Include the patient and family in care decisions to promote a sense of control and cooperation.
Refer to spiritual counselor: Offer spiritual support if desired by the patient and family.

6. Providing Patient Education and Teachings for Lifestyle Changes

Patient education is essential for long-term management of angina and prevention of disease progression.

Patient Education Points:

Assess readiness to learn: Evaluate the patient’s readiness to learn, cultural background, and specific information needs.
Discuss nonmodifiable risk factors: Educate about nonmodifiable risk factors for CAD.
Review cholesterol levels: Explain the importance of cholesterol levels, LDL, and HDL, and the need for regular monitoring.
Explain pathophysiology: Discuss the underlying pathophysiology of angina and the importance of preventing and managing attacks.
Identify stress sources: Help patients identify physical and emotional stressors and develop strategies for avoidance.
Avoid angina triggers: Educate patients on avoiding situations that precipitate angina, such as stress, exertion, heavy meals, and extreme temperatures.
Educate women on angina symptoms: Inform women about atypical angina symptoms, such as shortness of breath, fatigue, and nausea.
Emphasize lifestyle modifications: Review the importance of weight control, smoking cessation, dietary changes, and regular exercise.
Encourage cardiac rehabilitation: Promote participation in cardiac rehabilitation programs and caution against overexertion.
Discuss impact on lifestyle: Address the impact of angina on work, driving, sexual activity, and hobbies.
Demonstrate self-monitoring: Teach patients how to monitor their pulse and blood pressure during activities.
Explain angina attack management: Educate on steps to take during angina attacks, including stopping activity, using nitroglycerin, and relaxation techniques.
Caution against herbal remedies: Advise against using certain herbal plants and medications that may interfere with cardiac medications.
Promote smoking cessation: Strongly encourage participation in smoking cessation programs.
Review prescribed medications: Ensure understanding of all prescribed medications, their purpose, dosage, and side effects.
Discuss aspirin and antiplatelet agents: Explain the use of aspirin and other antiplatelet agents for preventing clot formation.
Review reportable symptoms: Educate patients on symptoms to report to their healthcare provider, such as increased frequency of attacks or changes in medication response.
Emphasize follow-up appointments: Stress the importance of regular follow-up appointments for ongoing monitoring and treatment adjustments.

Evaluation of Nursing Care

Patient outcomes are evaluated based on the goals set during the planning phase.

Expected Patient Outcomes:

Pain is effectively relieved.
Anxiety levels are reduced.
Patient demonstrates understanding of how to avoid complications.
Patient adheres to the prescribed self-care program.

Discharge and Home Care Guidelines

Discharge planning focuses on ensuring a smooth transition to home care and continued management of angina.

Home Care Instructions:

Reduce anginal attacks: Plan activities to minimize angina episodes.
Follow-up monitoring: Remind patients about scheduled follow-up appointments, blood tests, and ECGs.
Therapeutic regimen compliance: Home care nurses monitor patient adherence to diet, medications, and lifestyle modifications.

Documentation Guidelines

Accurate documentation is essential for continuity of care and legal purposes.

Documentation Should Include:

Nature, extent, and duration of chest pain.
Impact on patient’s independence and lifestyle.
Characteristics of pain, triggers, and relieving factors.
Pulse and blood pressure readings.
Patient’s fear and anxiety levels.
Family and SO responses and actions.
Deviations from treatment plan and patient’s reasons.
Consequences of actions to date.
Plan of care and teaching plan.
Response to interventions and teaching.
Progress toward desired outcomes.
Modifications to the care plan.

Recommended Resources

Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health

References and Sources

Alaeddini, J., & Yang, E. H. (2018, July 19). Angina Pectoris: Practice Essentials, Background, Pathophysiology. Medscape Reference.
Aroesty, J. M., & Kannam, J. P. (2022, June). Patient education: Chest pain (Beyond the Basics). UpToDate.
Boyette, L. C., & Manna, B. (2022, July 11). Physiology, Myocardial Oxygen Demand – StatPearls – NCBI Bookshelf. NCBI.
de Heer, E. W., Palacios, J. E., Ader, H. J., van Marwijk, H. W.J., Tylee, A., & van der Feltz-Cornelis, C. M. (2020, February). Chest pain, depression and anxiety in coronary heart disease: Consequence or cause? A prospective clinical study in primary care. Journal of Psychosomatic Research, 129.
Doenges, M. E., Murr, A. C., & Moorhouse, M. F. (2010). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span. F.A. Davis Company.
Farzam, K., & Jan, A. (2022, July 21). Beta Blockers – StatPearls – NCBI Bookshelf. NCBI.
Haber, M. D., & Brenner, B. E. (2021, January 25). Angina Pectoris in Emergency Medicine: Background, Pathophysiology, Epidemiology. Medscape Reference.
Harvard Health Publishing. (2020, November 1). Stress-induced brain activity linked to chest pain from heart disease. Harvard Health.
Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-surgical Nursing. Wolters Kluwer.
Moazzami, K., Wittbrodt, M. T., Alkhalaf, M., Lima, B. B., Nye, J. A., Mehta, P. K., Quyyumi, A. A., Vaccarino, V., Bremner, J. D., & Shah, A. J. (2020, August). Association Between Mental Stress-Induced Inferior Frontal Cortex Activation and Angina in Coronary Artery Disease. Circulation: Cardiovascular Imaging, 13(8).
Shah, S. N., & Ali, Y. S. (2021, April 9). Coronary Artery Atherosclerosis: Practice Essentials, Background, Anatomy. Medscape Reference.
Tan, W., & Yang, E. H. (2020, October 1). Unstable Angina: Practice Essentials, Background, Pathophysiology. Medscape Reference.

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