About
Chest pain occurring in varying degrees with ( stable) or without ( unstable) activity. May require prompt evaluation and treatment if persistent and severe.
Assess
Chest pain and discomfort, radiation, syncope, shortness of breath, activity level; frequency, location, duration, and intensity of symptoms
Complications
Myocardial infarction; death
Diagnosis
- Activity intolerance related to impaired cardiac oxygenation
- Acute pain related to impaired oxygenation to heart muscle
- Knowledge deficit related to symptom management and when to seek emergency help
Goals
- The client will be free from pain.
- The client will be free from chest pain with activity.
- The client will identify treatment strategies and indicate when it would be necessary for emergent treatment.
Interventions
- Assess vital signs, pulse oximetry, and pain levels.
- Monitor vital signs, electrolytes, fluid balance, intakes and outputs.
- Monitor onset, location, precipitating factors, alleviating factors, intensity of chest pain.
- Monitor electrolytes, serial troponins and other cardiac enzymes, telemetry.
- Perform an EKG as indicated.
- Administer oxygen, nitrates, analgesics, and other medications as ordered.
- Prepare client for additional diagnostics as indicated ( echocardiogram, stress tests, carotid doppler, etc).
- Teach client about medications, including when to take, route of administration, and when to return for emergent treatment.
- Monitor for signs/ symptoms of complications.
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