Chest PainChest PainDifferentiating Causes and Differentiating Causes and

Patient PresentationsPatient Presentations

June 2009

ObjectivesObjectives

Differentiate the characteristics of cardiac Differentiate the characteristics of cardiac and non cardiac causes of chest painand non cardiac causes of chest pain

Identify gender,age and differences in Identify gender,age and differences in presentation of cardiac related chest painpresentation of cardiac related chest pain

Discuss the Kaleida Health Chest Pain Discuss the Kaleida Health Chest Pain protocolprotocol

Patient Scenario #1Patient Scenario #1

A 62 year old male presentsA 62 year old male presents

to you with a tingling to you with a tingling

sensation in his neck-sensation in his neck-

he points to the area he points to the area

of the carotid arteries. He has a vague of the carotid arteries. He has a vague

sense that something is wrong…..what sense that something is wrong…..what will you do??will you do??

Patient Scenario #2Patient Scenario #2

A 32 year old female complains of A 32 year old female complains of extreme fatigue . Her resting heart extreme fatigue . Her resting heart rate is 125 and she feels rate is 125 and she feels “lightheaded”…“lightheaded”…

What else do you want to know?What else do you want to know?

Patient Scenario #3Patient Scenario #3

A 38 year old construction worker A 38 year old construction worker complains of a work related injury. He complains of a work related injury. He has tearing like pain in his shoulder has tearing like pain in his shoulder that radiates to his back…What other that radiates to his back…What other assessments will you perform?assessments will you perform?

Sources of Chest PainSources of Chest PainPain in the chest can originate from Pain in the chest can originate from many body systems, including the many body systems, including the

heartheart

CardiacCardiac PulmonaryPulmonary GastrointestinGastrointestin

alal

MetabolicMetabolic MusculoskeletMusculoskelet

alal HematologicalHematological

Non Cardiovascular causes of Non Cardiovascular causes of chest pain…chest pain…

a multi system diagnostic dilemmaa multi system diagnostic dilemma PulmonaryPulmonary

Pulmonary Embolism, Pulmonary Pulmonary Embolism, Pulmonary Hypertension, Pneumothorax, Pleuritis, Hypertension, Pneumothorax, Pleuritis, PneumoniaPneumonia

GastrointestinalGastrointestinal

GERD, Esophageal rupture,Peptic Ulcer, GERD, Esophageal rupture,Peptic Ulcer, Esophageal spasm, Pancreatitis, Esophageal spasm, Pancreatitis, CholecystitisCholecystitis

Non Cardiovascular causes of Non Cardiovascular causes of chest pain…chest pain…

a multi system diagnostic dilemmaa multi system diagnostic dilemma

Hematologic Hematologic

severe anemia, sickle cell crisissevere anemia, sickle cell crisis

MusculoskeletalMusculoskeletal

Costochrondritis, rib fracturesCostochrondritis, rib fractures

Cardiac related chest Cardiac related chest pain..still many potential pain..still many potential

causes… causes… Myocardial InfarctionMyocardial Infarction Unstable AnginaUnstable Angina PericarditisPericarditis Cardiac TamponadeCardiac Tamponade Aortic Stenosis & DissectionAortic Stenosis & Dissection CardiomyopathyCardiomyopathy

APQRSTAPQRSTa a Mnemonic for the evaluation of Mnemonic for the evaluation of

Chest PainChest Pain

AA= Associated symptoms= Associated symptoms

PP= Precipitating factors and palliation= Precipitating factors and palliation

QQ= Quality= Quality

RR= Region,radiation= Region,radiation

SS= Severity= Severity

TT= Timing= Timing

AAssociated symptoms-ssociated symptoms-CirculatoryCirculatory

Tachycardia/BradycardiaTachycardia/Bradycardia Hypertension/HypotensionHypertension/Hypotension PalpitationsPalpitations Change in heart sounds-Change in heart sounds-

murmur,rub,distant or muffledmurmur,rub,distant or muffled

AAssociated symptoms- ssociated symptoms- PulmonaryPulmonary

Shortness of breathShortness of breath DyspneaDyspnea Decreased or absent breath soundsDecreased or absent breath sounds Crackles, wheezing to auscultationCrackles, wheezing to auscultation CoughCough

AAssociated Symptoms-ssociated Symptoms-NeurologicNeurologic

Change in mental statusChange in mental status DizzinessDizziness SyncopeSyncope

Additional Additional AAssociated ssociated symptomssymptoms

FatigueFatigue Sleep disturbanceSleep disturbance WeaknessWeakness Nausea and vomitingNausea and vomiting DiaphoresisDiaphoresis Anxiety-impending doomAnxiety-impending doom

PPrecipitatingrecipitating Factors/PalliationFactors/Palliation

ExertionExertion EatingEating Cold exposureCold exposure Activity/Movement/Change of Activity/Movement/Change of

positionposition PalpationPalpation InspirationInspiration

Precipitating Precipitating Factors/Factors/PPalliationalliation

Relieved with:Relieved with: RestRest Position changePosition change NitroglycerineNitroglycerine AntacidAntacid

QQualityuality

HeavinessHeaviness CrushingCrushing Tight/SqueezingTight/Squeezing StabbingStabbing BurningBurning

Sharp/dullSharp/dull AchingAching PressurePressure NumbnessNumbness

RRegion,egion,RRadiationadiation

Located Located

substernal, retrosternal, left or right substernal, retrosternal, left or right chest ,midback, shoulder, neck, jawchest ,midback, shoulder, neck, jaw

Radiates toRadiates to

jaw, arm, back, shoulder, jaw, arm, back, shoulder, abdomen,neckabdomen,neck

SSeverityeverity

Use the 0-10 faces/numeric scaleUse the 0-10 faces/numeric scale

TTimingiming

Onset and durationOnset and duration Gradual or suddenGradual or sudden Intermittent or constantIntermittent or constant NocturnalNocturnal

TypicalTypical signs and symptoms signs and symptoms associated with associated with

Acute Coronary Syndrome (ACS)Acute Coronary Syndrome (ACS) Crushing, oppressive, or constricting Crushing, oppressive, or constricting

pain or feeling, or pressure that may pain or feeling, or pressure that may radiate to left arm, neck and jaw, radiate to left arm, neck and jaw, shoulder or epigastric areashoulder or epigastric area

Nausea, vomiting, diaphoresis, Nausea, vomiting, diaphoresis, palpitations, dyspneapalpitations, dyspnea

Cool, clammy skinCool, clammy skin

Gender differences in ACS Gender differences in ACS presentationpresentation

Both men and women may present with “classic” Both men and women may present with “classic” chest pain, diaphoresis, SOBchest pain, diaphoresis, SOB

Women may have more jaw and neck pain Women may have more jaw and neck pain Women may have a greater tendency to have Women may have a greater tendency to have

atypical chest pain-abdominal pain dyspnea, atypical chest pain-abdominal pain dyspnea, nausea/indigestion, unexplained /unusual nausea/indigestion, unexplained /unusual fatigue,numbness in the hands,palpitations*fatigue,numbness in the hands,palpitations*

*This rather vague group of symptoms is is *This rather vague group of symptoms is is considered atypical and is common to many less considered atypical and is common to many less

serious health problems.serious health problems. DeVon,Ryan,Ochs,Shapiro AJCC January 2008 Volume 17 No.1DeVon,Ryan,Ochs,Shapiro AJCC January 2008 Volume 17 No.1

Age variation in ACS Age variation in ACS presentationpresentation

Symptoms experienced by older adults Symptoms experienced by older adults (age > 65) are more diffuse and and (age > 65) are more diffuse and and potentially milderpotentially milder

Fatigue and SOB (breathlessness)Fatigue and SOB (breathlessness) were major presenting symptoms , only were major presenting symptoms , only 55% had chest pain55% had chest pain

Lindgren et al Nursing Research January/February 2008 Vol 57 No.1Lindgren et al Nursing Research January/February 2008 Vol 57 No.1

Other impacts on ACS Other impacts on ACS presentationpresentation

DiabetesDiabetes-( neuropathy) more likely -( neuropathy) more likely to present with weakness, dyspnea to present with weakness, dyspnea and nauseaand nausea

HypertensionHypertension, , prior strokeprior stroke and and heart failureheart failure may cause decrease in may cause decrease in perceived chest painperceived chest pain

DeVon & Ryan: Journal of Cardiovascular Nursing July/August 2005 Vol 20 No.4DeVon & Ryan: Journal of Cardiovascular Nursing July/August 2005 Vol 20 No.4

Patient Scenario #1Patient Scenario #1

A 62 year old male presentsA 62 year old male presents

to you with a tingling to you with a tingling

sensation in his neck-sensation in his neck-

he points to the area he points to the area

of the carotid arteries. He has a vague of the carotid arteries. He has a vague

sense that something is wrong…..what sense that something is wrong…..what

else do you want to know?else do you want to know?

Patient Scenario #1Patient Scenario #1

A 68 year old male presentsA 68 year old male presents

to you with a tingling to you with a tingling

sensation in his neck-sensation in his neck-

he points to the area he points to the area

of the carotid arteries. He has a vague of the carotid arteries. He has a vague

sense that something is wrong…..what sense that something is wrong…..what

else do you want to know??else do you want to know??

Is he diabetic ? Do the APQRSTIs he diabetic ? Do the APQRST

Patient Scenario #2Patient Scenario #2

A 32 year old female complains of A 32 year old female complains of extreme fatigue . Her resting heart rate extreme fatigue . Her resting heart rate is 125 and she feels “lightheaded”…is 125 and she feels “lightheaded”…

Does her age mean that she is not Does her age mean that she is not having a cardiac event?having a cardiac event?

Patient Scenario #2Patient Scenario #2

A 32 year old female complains of extreme fatigue . Her A 32 year old female complains of extreme fatigue . Her resting heart rate is 125 and she feels “lightheaded”… resting heart rate is 125 and she feels “lightheaded”… Does her age mean she is not having a cardiac event?Does her age mean she is not having a cardiac event?

No-No-

When did the symptoms begin? Was it a sudden onset?When did the symptoms begin? Was it a sudden onset?

Finish the APQRSTFinish the APQRST

Patient Scenario #3Patient Scenario #3

A 38 year old construction worker A 38 year old construction worker complains of a work related injury. He complains of a work related injury. He has tearing like pain in his shoulder has tearing like pain in his shoulder that radiates to his back…What other that radiates to his back…What other assessments will you perform?assessments will you perform?

Patient Scenario #3Patient Scenario #3

A 38 year old construction worker complains of a work A 38 year old construction worker complains of a work related injury. He has tearing like pain in his shoulder that related injury. He has tearing like pain in his shoulder that radiates to his back…What other assessments will you radiates to his back…What other assessments will you perform?perform?

Assess character, radiation ,intensity and onset of the pain.Assess character, radiation ,intensity and onset of the pain.Assess vital signsAssess vital signsAsk about what activity he feels initiated the painAsk about what activity he feels initiated the painFinish the APQRST…Finish the APQRST…

Chest PainChest Pain Remember that Chest Pain may Remember that Chest Pain may

indicate a critical lack of oxygen to the indicate a critical lack of oxygen to the heartheart

Or…Or… Be a result of an alteration in another Be a result of an alteration in another

body systembody systemHoweverHowever

All chest pain should be treated as All chest pain should be treated as cardiac until proven otherwisecardiac until proven otherwise

Chest Pain ProtocolChest Pain ProtocolAA. . Assessment/Data Collection:Assessment/Data Collection: Assess with onset of chest pain:Assess with onset of chest pain: Location, radiation, character, duration, intensity, skin Location, radiation, character, duration, intensity, skin

temp, color, nausea, vomiting, diaphoresis, shortness of temp, color, nausea, vomiting, diaphoresis, shortness of breath, precipitating factors (i.e. movement, deep breath, precipitating factors (i.e. movement, deep inspiration, palpitation), relieving factors, and any inspiration, palpitation), relieving factors, and any similarities to previous pain.similarities to previous pain.

KEYPOINT: Ask the patient to rate the pain on a scale from 1-KEYPOINT: Ask the patient to rate the pain on a scale from 1-10, 10 being the worst possible pain, and document on 10, 10 being the worst possible pain, and document on appropriate flowsheet.appropriate flowsheet.

BP, HR, RR, and heart rhythm (if on monitor)BP, HR, RR, and heart rhythm (if on monitor) Evaluate BP before and five (5) minutes after each Evaluate BP before and five (5) minutes after each

administration of antianginal medication (If physician has administration of antianginal medication (If physician has ordered these medications).ordered these medications).

Assess for pain relief and any associated symptoms after Assess for pain relief and any associated symptoms after each administration of antianginal medications (If each administration of antianginal medications (If physician has ordered these medications).physician has ordered these medications).

Vital signs Q4H.Vital signs Q4H.

Chest Pain ProtocolChest Pain Protocol

B.B. Care and Management: Care and Management: Administer Oxygen at 2 L/minute until physician Administer Oxygen at 2 L/minute until physician

order received.order received. Obtain ECG for all occurrences of new onset and Obtain ECG for all occurrences of new onset and

recurrent, unresolved chest pain.recurrent, unresolved chest pain.KEYPOINT: In long-term care, obtain physician order KEYPOINT: In long-term care, obtain physician order

for ECG.for ECG. Maintain bedrest during episode of acute pain.Maintain bedrest during episode of acute pain. Maintain quiet and restful environment during Maintain quiet and restful environment during

episode of pain.episode of pain. Provide reassurance to the patient and family.Provide reassurance to the patient and family.

Chest Pain ProtocolChest Pain Protocol

C. C. Complications/Reportable Complications/Reportable Situations:Situations:

Notify physician/ licensed independent Notify physician/ licensed independent practitioner for:practitioner for:

all occurrences of new onset/unresolved all occurrences of new onset/unresolved chest pain and associated assessment.chest pain and associated assessment.

changes in heart rhythm (when patient is changes in heart rhythm (when patient is continuously monitored).continuously monitored).

deterioration of vital signs from baseline.deterioration of vital signs from baseline. D.D.Safety and Prevention:Safety and Prevention:Avoid valsalva maneuver.Avoid valsalva maneuver.

Chest Pain ProtocolChest Pain Protocol

Patient/Family Education:Patient/Family Education:

Instruct patient and/or significant other to:Instruct patient and/or significant other to: inform a staff member of all episodes of inform a staff member of all episodes of

chest discomfort or associated symptoms.chest discomfort or associated symptoms. inform a staff member immediately after inform a staff member immediately after

taking NTG, if ordered at the bedside.taking NTG, if ordered at the bedside. maintain bedrest during episode of chest maintain bedrest during episode of chest

pain.pain. avoid valsalva maneuvers.avoid valsalva maneuvers.