Zusammenfassung der Ressource
Chest Pain
- GTN Protocol
- first dose RN must administer
- Redo
- pain assessment
- ECG
- Observations
- Check 6 rights 3 checks
- SL route
- dont swallow
- Dont chew
- allow it to dissolve under the tongue
- Explain why, medication wont work effectively
- Spray or tablet
- every 5 minutes
- max dose
- 1800mcg
- No resolution call MET
- max 3 doses
- WH if systolic less than 100
- Discuss side effects
- nausea
- dizzy
- light headed
- Drop in BP
- falls risk
- bed pan/ bottle
- ensure buzzer is close
- Positioning
- sit the patient up
- ECG
- Document if during pain or post
- ? hairy, clammy, large breasted
- remove the bra
- shave hair
- V1 & V2 4th intercostal space either side of sternum
- V4 mid clavicular line bellow nipple
- V6 mid axillary line
- V3 betweel V4 and V2
- V5 between V4 and V6
- Ensure patient breaths normally
- Ensure patient remains still
- Ensure patient doesn't cross their legs
- Ensure patient privacy
- pain assessment PQRSTU
- Provoke
- what makes it worse what makes it better
- Quality
- Describe the pain, sharp, dull, chrushing
- Radiation
- Does the pain move, throat, neck, arm
- Severity
- How would you score the pain 0-10
- Timing
- When did it start, how long for
- Understanding
- Have you had this before what did you do last time
- Get help
- Call MO
- ISBAR
- obs
- medication
- Call RN
- assistance with patient
- bring GTN
- Bring ECG
- Call Supervisor
- delegate patient load