Chest Pain Nursing Diagnosis and Interventions

Chest pain caused by heart burn is accompanied by a burning sensation. Chest pain, pressure or tightness that is not accompanied by a burning sensation is cause for immediate medical attention. Whenever chest pain is involved it is best to use caution.

Chest pain brings immediate thought of a heart attack. Heart problems are not the only causes of pain in the chest area.

A sudden pain is particularly alarming. It is true that chest pain may suggest heart disease. There are many other causes.


Nursing Diagnosis for Chest Pain

1. Acute pain related to tissue ischemia secondary to arterial occlusion, tissue inflammation.

2. Ineffective Tissue Perfusion: (heart muscle) related to decreased blood flow.

3. Activity intolerance related to imbalance between oxygen supply and metabolic needs of tissues.

Nursing Interventions for for Chest Pain

The principles of action:

1. Bed rest (bed rest) with Fowler position / semi-Fowler.
2. Perform 12 lead EKG, 24 lead if necessary.
3. Observation of vital signs.
4. Collaboration of oxygen and delivery of analgesic drugs and drug side effects observed.
5. Install a drip and give peace to the client.
6. Taking blood samples.
7. Reduce environmental stimuli.
8. Be calm in the works.
9. Observe signs of complications

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Assessment Nursing Care Plan for Chest Pain

Common signs and symptoms that accompany chest pain are:

• Heartburn
• Headache
• Pain that is projected onto the arm, neck, back
• Diaphoresis / sweating
• Shortness of breath
• Tachycardia
• Pale
• Difficulty sleeping (insomnia)
• Nausea, vomiting, anorexia
• Anxiety, nervous, focus on yourself
• Weakness
• The face tense, m erintih, crying
• Changes in consciousness

Primary Assessment - Nursing Care Plan for Chest Pain

a. Airway
- How airway clearance?
- Is there any obstruction / accumulation of secretions in the airway?
- How to breath sounds, is there any additional breath sounds?

b. Breathing
- What is the pattern of breath? frequency? the depth and rhythm?
- What is the use of auxiliary respiratory muscles?
- Are there any additional breath sounds?

c. Circulation
- How does the peripheral arteries and carotid arteries? quality (content and voltage)
- How capillary refill, what there is akral cold, cyanosis or oliguria?
- Is there a decrease in consciousness?
- How vital signs? blood pressure, temperature, pulse, respiration?


2. Secondary Assessment - Nursing Care Plan for Chest Pain

Important things that need to be studied further in chest pain (coronary):

a. location of pain
Where to start, propagation (coronary chest pain: from the sternal border radiating to the neck, chin or shoulder to the left arm of the ulna)

b. The nature of pain
Feeling of fullness, heaviness such as seizures, squeezing, stabbing, choking / burning, etc..

c. Characteristics of pain
Degree of pain, duration, how many times arise in a given time period.

d. chronological pain
Beginning there is pain and progress in sequence

e. Circumstances at the time of the attack
Whether arising in times / circumstances

f. Factors that reinforce / relieve pain such as attitude / posture, movement, pressure, etc..

g. Other symptoms that may be present whether or not the relationship with chest pain.

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