Nurse Practitioner. CLINICAL PROTOCOL Chest Pain

Transcription

1 Nurse INTRODUCTION: Patients presenting with chest pain require rapid evaluation. Myocardial ischaemia should be considered in all patients presenting with chest pain. Assessment of pain type and referral, and response of pain to various interventions is important in differentiating between cardiac and non-cardiac chest pain. If the pain is cardiac in nature it is important to respond quickly to ensure the best possible outcome for the Pt. DIFFERENTIAL DAIGNOSIS: CVS CAUSES; AMI, unstable angina, aortic dissection, aortic aneurysm, pericarditis, aortic stenosis, mitral valve prolapse. RESP CAUSES; pulmonary embolism, pneumothorax, severe pneumonia. GI CAUSES; oesophageal spasm or rupture, gastric reflux, indigestion, perforated peptic ulcer. Musculoskeletal causes. Trauma or neoplasm. Psychiatric causes. Nurse Medical +/- Nurse Presenting History CLINICAL PRACTICE GUIDELINE Scope Chest pain responsive to protocols Identify patients suitable for outlined within this CP. NP clinical protocol. Refer unsuitable pts. to current GP. Chest pain unresponsive to treatment outlined within this CP. Evidence/suspicion of AMI or more serious cause of pain. Initial Assessment and Interventions Relevant past medical Hx and medication history Known allergies Pt. describes pain as squeezing, pressing, constricting, and heavy in central chest, +/- radiating to left arm, neck or jaw. Pt. may feel a sense of impending doom. Identify patients not suitable for NP CP and redirect to usual GP care +/- ED Identify patients not suitable for NP CP and redirect to usual GP care +/- ED

2 Physical examination Pain assessment Nurse Primary survey ABC Vital signs (T, P, R, BP), ECG if available. Signs of ST elevation refer GP/ED for thrombolysis. Assess pain: time of onset, position of pain including any radiation, description of pain, severity of pain, length of time pain has been present, frequency of pain episodes, what were you doing when the pain started, does anything make it better or worse, is it reproducible by palpation Any nausea, epigastric discomfort? Note any diaphoresis. Any SOB or dizziness Is the Pt. pale? Be aware of atypical signs/symptoms: No chest pain, but pain related to exertion or stress in the left arm or jaw. Epigastric discomfort. Unexplained fatigue. Indigestion, belching. Dizziness Pain in the right arm. Confusion. Assess associated vascular risk factors (eg strong family Hx). Asses level of pain using appropriate pain scale. Morphine 2.5 5mg IV then titrate to effect if required (GP only). Identify patients not suitable for NP CP exit CP and refer to current GP. Determine need for and type of analgesia required. Investigations Pathology Troponin, FBC, U&E, CK, LFT s Refer to GP for ongoing management. Imaging CXR if respiratory cause suspected. Diagnosis of cause of pain and application of correct treatment regime. Patient Education / Follow-up Follow up appointment Verbal instruction to patient: Review appointment may be indicated by pathology results; NP to contact patient to schedule follow-up Ensure patient understands problem, treatment and follow up.

3 Patient Education Medication instructions appointment. Nurse Verbal instruction and patient information handout if required and appropriate. Patient understanding of the problem, treatment and measures which may reduce the risk of ongoing complications. Verbal/written instructions from NP/GP Ensure patient understands problem, treatment and follow up Referrals Referrals may be required for specific patient problems or as required to: Physiotherapy Drug and alcohol counsellor Other problems outside of NP scope of practice Certificates Absence from work certificates Certificate of attendance Letter Copy of notes to GP / Specialist or acute care facility Interpretation of results and management decisions Patients with problems outside the NPs scope of practice are referred to appropriate health care providers. Ensure appropriate documentation completed Ensure continuity of care and referral to health care team GP hospital admission Outcome All medications will be stored, labelled and dispensed in accordance with hospital policy and relevant legislation

4 Initial management pathway Nurse Reassure Pt. Place Pt. in an upright position Give O2 2-4 L/nasal cannula if available. Assess vital signs (ECG if available) Assess chest pain Administer sublingual glyceryl trinitrate as prescribed Assess vital signs If no response to glyceryl trinitrate refer to current GP for further advice and management. If Pt. experiences a cardiac arrest commence basic life support/advanced life support as per facility protocol. Documentation and referral to current GP, transfer to nearest Emergency department. If no responsee after 5 mins Repeat sublingual glyceryl trinitrate Assess vital signs If no responsee after 5 mins Repeat sublingual glyceryl trinitrate Assess vital signs If pain is unresolved after 20 mins (3 doses of glyceryl trinitrate) CALL 000 FOR AN AMBULANCE Administer 300mgs Aspirin Reassess Pt. every 5 mins Administer analgesia if required Maintain airway if necessary Continue to reassure Pt.

5 Nurse Goals of Treatment Relief of symptoms Prevention of recurrence Prevention of complications Drug Formulary FORMULARY GLYCERYL TRINITRATE ASPIRIN Drug (generic name): Glyceryl Trinitrate Drug (generic name): Aspirin Dosage range: 400 mgs (spray) OR 600microgram (tablet) Dosage range: mg Route: oral (sublingual) Route: oral Frequency of administration: 5 minutely if pain persists Frequency of administration: immediately Duration of order: as required max of 3 metered doses, or 3 Duration of order: single dose tablets (1800 micrograms). Actions: immediate antiplatelet effect, produces complete Actions: Venodialting effects, reduction in venous return and inhibition of thromboxane-mediated platelet aggregation preload to the heart therefore reducing myocardial oxygen within 30 minutes. requirement. Indications for use: Acute chest pain with suspicion of acute Indications for use: Prevention and treatment of angina, coronary syndrome. acute heart failure associated with MI. Contraindications for use: Known NSAID hypersensitivity Contraindications for use: hypovolaemia, raised ICP, G6PD (esp. asthma). deficiency (risk of haemolytic anaemia). Adverse drug reactions: bleeding, GI upset, Adverse drug reactions: headache, flushing, palpitations, fainting, peripheral oedema. Rarely rebound angina. Unexpected representation NP Clinical Practice Evaluative strategies Review Patient Notes. Full audit of clinical events. NP Clinical Practice/Medical Report Audit

6 Nurse Key Terms NP Nurse CP Clinical Protocol GP General S4 Schedule of the drug administration act References 1. Australian Medicines handbook (internet). 2011, Nov. Accessed 2011 Dec 1 at 2. etg complete (internet). Melbourne: Therapeutic Guidelines Limited; 2011 Nov. Accessed 2011 Dec 1 at This CP was originally written by: Carol Jones Nurse Murray Medical Centre Mandurah Authorship, Endorsement and acknowledgement Reviewed and authorised by: Dr. Frank Reedman Jones MBBCh, DCH, DRCOG, FRACGP, FACRRM Murray Medical Centre: Primary Care Physician We acknowledge the authorship and input of : Dr. Eileen Bristol MBChB,MRCGP,DRCOG,FRACGP Murray Medical Centre: Primary Care Physician Carol Jones RN, RM, PGradDipNurse, NP Nurse Date Written: November 2011 Review Date: November 2013