Set of activities performed by the nurse immediately to the patient presenting with non-specific chest pain. Definition of non-specific chest pain: any significant pain in adults, lasting more than a few seconds, with no apparent relation to trauma or visible or palpable chest lesions.
Objectives:
– To relieve the pain presented by the patient. – Decrease anxiety of the patient and family.
Equipment:
– Electrocardiograph. – Equipment necessary for Oxygen Therapy, if applicable. – Equipment needed for Peripheral Catheter Insertion Technique. – Sphygmomanometer. – Stethoscope.
Material:
– Non-sterile gloves. – Specific medication. – Necessary material for oxygen therapy, if applicable. – Material necessary for Peripheral Catheter Insertion Technique. – Nursing records.
Procedure:
– Assess the characteristics of the pain and accompanying symptoms. – Place the patient in Fowler’s position or the most comfortable position for the patient. – Obtain electrocardiogram. – Notify the physician. – Reassure the patient and family. – Preserve the patient’s privacy. – Take heart rate and blood pressure. – Administer oxygen in goggles at 2 liters per minute, if there is respiratory distress. – Assess the need for a venous line.
– Inform the patient and family at all times of the procedures being performed in order to alleviate anxiety. – Ask the patient to inform us of any change in pain or symptoms. – Record in the nursing documentation: procedure performed, date and time, incidences and patient response.
Observations:
– In the presence of any acute chest or epigastric pain there is a possibility of acute myocardial infarction or angina pectoris. It can range from discomfort to a sensation of heaviness or intense pain with or without irradiation to the neck, jaw, shoulder, left arm or epigastrium. – In case of a critical situation and if the physician so decides, prepare for transfer to the ICU according to procedure 1.3.
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