Chest Pain

Chest Pain

1. 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

2. Positioning

   • sit the patient up

3. 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

4. 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

5. Get help

   • Call MO
     • ISBAR
       • obs
       • medication
   • Call RN
     • assistance with patient
     • bring GTN
     • Bring ECG
   • Call Supervisor
     • delegate patient load