Chest Pain Care Plan

Abbey Wilson
Chest Pain Care Plan

Nursing Diagnosis 1: Risk for decreased cardiac tissue perfusion r/t tachycardia aeb
patient’s apical heart rate is 140bpm.
Interventions:
1. Observe for and report chest pain or discomfort; note location, radiation, severity,
quality, duration, and associated manifestations such as nausea, indigestion, or diaphoresis;
also note precipitating and relieving factors. Chest pain/discomfort may indicate an
inadequate blood supply to the heart, which can further compromise cardiac
output. EB: Clients with decreased cardiac output may present with myocardial ischemia. Those
with myocardial ischemia may present with decreased cardiac output and HF (Amsterdam et al,
2014; Yancy et al, 2013).
2. Perform a 12-lead ECG as ordered to be interpreted within 10 minutes of emergency
department arrival and during episodes of chest discomfort or angina equivalent. EB: A
12-lead ECG should be performed within 10 minutes of emergency department arrival for all
clients who are having chest discomfort. ECGs are used to identify the area of ischemia or injury,
such as ST depressions or elevations, new left-bundle branch block, T-wave inversions, and/or
Q-waves, and to guide treatment (Amsterdam et al, 2014; O'Gara et al, 2013).
3. Assess and report abnormal laboratory work results of cardiac enzymes, specifically
troponin I or T, B-type natriuretic peptide, chemistries, hematology, coagulation studies,
arterial blood gases, finger stick blood sugar, elevated C-reactive protein, or drug
screen. EB: Abnormalities can identify the cause of the decreased perfusion and identify
complications related to the decreased perfusion such as anemia, hypovolemia, coagulopathy,
drug abuse, hyperglycemia, kidney (renal) failure, and heart failure. Markedly elevated cardiac
enzymes are usually indicative of an MI, and the cardiac enzymes can also help determine short-
and long-term prognosis (Amsterdam et al, 2014).
Nursing Diagnosis 2: Acute pain r/t chest pain aeb patient reports “tightness” and
“pressure” in center of chest.
Interventions:
1. During the initial assessment and interview if the client is experiencing pain, or when
pain first occurs, conduct and document a comprehensive pain assessment, using
appropriate pain assessment tools. CEB/EBN: Determining location, temporal aspects, pain
intensity, characteristics, and the effect of pain on function and quality of life are critical to
determine the underlying cause of pain and effectiveness of treatment (McCaffery, 1968; Drew &
Peltier, 2018).
2. Teach the client to use the self-report pain tool to rate the intensity of past or current
pain. EB: It is often difficult for clients to understand the concept of pain and describe their pain
experience. Using alternative words and providing a complete description of the assessment
process, including the use of scales, ensures that an accurate treatment plan is developed (Drew
& Peltier, 2018).
3. Administer nitroglycerin tablets sublingually as ordered, every 5 minutes until the chest
pain is resolved while monitoring the blood pressure for hypotension, for a maximum of
three doses as ordered. Administer nitroglycerin paste or intravenous preparations as
ordered. EB: Nitroglycerin causes coronary arterial and venous dilation, and at higher doses
peripheral arterial dilation, reducing preload and afterload and decreasing myocardial oxygen
demand while increasing oxygen delivery (Amsterdam et al, 2014).
Nursing Diagnosis 3: Anxiety r/t chest pain aeb patient is tapping fingers, tachycardic,
tachypneic, and reports feeling anxious due to not knowing what is causing chest pain.
Interventions:
1. Assess the client's level of anxiety and physical reactions to anxiety (e.g., tachycardia,
tachypnea, irritability, restlessness). EBN: Barley & Lawson (2016) stated in their study of
health psychology's effects on common mental disorders that for nurses to deliver holistic care,
they must be alert to the possibility that the patient may be undergoing psychological anxiety and
then use appropriate communication skills to identify and manage this issue.
2. Use empathy to encourage the client to interpret the anxiety symptoms as normal. CEB:
The way a nurse interacts with a client influences his or her quality of life. Providing
psychological and social support can reduce the symptoms and problems associated with anxiety
(Wagner & Bear, 2009).
3. Explain all activities, procedures, and issues that involve the client; use nonmedical terms
and calm, slow speech then validate the client's understanding. EBN: In a study of the needs
of anxious and/or depressed patients, Kim (2016) found that nursing care must include
patient-centered undertakings to form a bond between patient and nurse, therefore reassuring
and empowering these patients.

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Abbey Wilson

Chest Pain Care Plan

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