Chest Pain

Chest Pain

GTN Protocol
1. first dose RN must administer
2. Redo
  1. pain assessment
  2. ECG
  3. Observations
3. Check 6 rights 3 checks
4. SL route
  1. dont swallow
  2. Dont chew
  3. allow it to dissolve under the tongue
  4. Explain why, medication wont work effectively
  5. Spray or tablet
5. every 5 minutes
  1. max dose
    1. 1800mcg
      1. No resolution call MET
  2. max 3 doses
  3. WH if systolic less than 100
6. Discuss side effects
  1. nausea
  2. dizzy
  3. light headed
  4. Drop in BP
    1. falls risk
      1. bed pan/ bottle
      2. ensure buzzer is close
Positioning
1. sit the patient up
ECG
1. Document if during pain or post
2. ? hairy, clammy, large breasted
  1. remove the bra
  2. shave hair
3. V1 & V2 4th intercostal space either side of sternum
  1. V4 mid clavicular line bellow nipple
  2. V6 mid axillary line
  3. V3 betweel V4 and V2
  4. V5 between V4 and V6
4. Ensure patient breaths normally
  1. Ensure patient remains still
  2. Ensure patient doesn't cross their legs
5. Ensure patient privacy
pain assessment PQRSTU
1. Provoke
  1. what makes it worse what makes it better
2. Quality
  1. Describe the pain, sharp, dull, chrushing
3. Radiation
  1. Does the pain move, throat, neck, arm
4. Severity
  1. How would you score the pain 0-10
5. Timing
  1. When did it start, how long for
6. Understanding
  1. Have you had this before what did you do last time
Get help
1. Call MO
  1. ISBAR
    1. obs
    2. medication
2. Call RN
  1. assistance with patient
  2. bring GTN
  3. Bring ECG
3. Call Supervisor
  1. delegate patient load

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	Created by TAFE Southbank Nursing about 6 years ago