Comfort: Chest Pain

Comfort:
Chest Pain

 

Related
To:
[Check
those that apply]
(_)
Myocardial Infarction
(_) Unstable Angina
(_) Coronary Artery Disease

(_) Chest Trauma
(_) Stress Anxiety

(_)
Musculoskeletal Disorders
(_) Pulmonary, Myocardial contusion
(_) Other:_____________________________
____________________________________

____________________________________

 

As
evidenced by:
[Check
those that apply]
Major:

(
Must be
present
)
(_)
Person reports or demonstrates a discomfort.
Minor:

(
May be
present
)
(_)
Increased BP (_) Diaphoresis (_) Dilated pupils (_)
Restlessness
(_) Facial mask of pain (_) Crying/moaning (_) Short of
breath (_) Anxiety

 

Date &
Sign.
Plan and Outcome
[Check
those that apply]
Target
Date:
Nursing Interventions
[Check
those that apply]
Date

Achieved:

  The
patient will:

(_)
Verbalize relief/control of pain.

(_) Verbalize
causative factors associated with chest pain.

(_) Other:

  (_)
Assess for causative factors asssociated:
  • Activity
  • Stress
  • Eating
  • Bowel elimination
  • Previous angina
    attack
  • Other:

(_) Assess
characteristing of chest pain.

  • Location
  • Intensity (Scale
    1-10)
  • Duration
  • Quality
  • Radiation

(_) Review history of
previous pain experienced by patient and compare to
current experience.

(_) Instruct patient
to report pain immediately.

(_) Continuous EKG
monitoring; note and record pattern during pain. Obtain
STAT 12-lead EKG per policy for acute changes noted on
continuous monitor.

(_) Provide a quiet,
restful environment.

(_) As per physician
order, administer IV analgesics in small increments until
pain is relieved or maximum dose is achieved. Monitor BP
during administration of pain meds. Assess pt. response
to pain medication and notify physician if pain is not
controlled or pt. experiences adverse reaction (decreased
BP, HA, distress).

(_) Administer
nitroglycerine as ordered by physician. Monitor as stated
above.

(_) Titrate IV Nitro
to achieve pain relief as ordered by physician. Monitor
hemodynamic response to medication (BP, urine output).

(_) Administer
supplemental oxygen as ordered by physician.

(_) Assist with ADL’s
to reduce cardiac stressors.

(_) Assist in
eliminating causative factors as identified by patient
assessment.

(_)
Other:________________
________________________
________________________
________________________

 

 

__________________________
Patient/Significant other signature

 

__________________________
RN signature