Chest pain can come from the heart, lungs, stomach, or muscles, but the nurse treats it as cardiac until proven otherwise. Fast assessment and an ECG are key. Your priorities are relieving pain, protecting the heart, and easing anxiety.
A · AssessmentD · DiagnosisP · PlanningI · InterventionE · Evaluation
Each care plan below follows the nursing process (ADPIE).
CARE PLAN 1 · NURSING DIAGNOSIS
PLANNING · EXPECTED OUTCOMES
ASSESSMENT
Acute Pain
Related to
- Reduced blood flow to the heart muscle
- Possible other causes such as pulmonary embolism or reflux
As evidenced by
- Client reports chest pressure, tightness, or burning
- Pain that may spread to the arm, jaw, or back
- Diaphoresis, tachycardia, and guarding
Short-term goals
- Client reports pain decreasing within 15 to 30 minutes of treatment
Long-term goals
- Client is free of chest pain and knows when to seek help
- Pain using PQRST (provoking factors, quality, radiation, severity, time)
- Vital signs and SpO2
- 12-lead ECG within 10 minutes of arrival
- Cardiac troponin as ordered
| INTERVENTION | RATIONALE |
|---|---|
| Obtain a 12-lead ECG right away | It quickly shows if the heart muscle is injured. |
| Give oxygen if SpO2 is below the ordered goal | Oxygen helps when saturation is low. |
| Give aspirin and nitroglycerin as ordered, checking BP before nitroglycerin | Aspirin reduces clotting and nitroglycerin improves blood flow, but nitroglycerin can drop BP. |
| Keep the client on bed rest during pain | Rest lowers oxygen demand on the heart. |
EVALUATION
- Client reports pain relief
- ECG and troponin results are reviewed and reported
- Vital signs stay stable
CARE PLAN 2 · NURSING DIAGNOSIS
PLANNING · EXPECTED OUTCOMES
ASSESSMENT
Anxiety
Related to
- Fear of a heart attack or dying
- Unfamiliar hospital setting
As evidenced by
- Restlessness
- Client states feeling scared
- Rapid breathing and heart rate
Short-term goals
- Client reports feeling calmer within 1 hour
Long-term goals
- Client uses coping strategies and understands the plan of care
- Anxiety level and nonverbal cues
- Vital signs
- Understanding of tests and procedures
| INTERVENTION | RATIONALE |
|---|---|
| Stay with the client and speak calmly | Presence and calm words lower fear. |
| Explain tests and procedures in simple terms | Knowing what to expect reduces anxiety. |
| Teach slow, deep breathing | Slow breathing lowers heart rate and oxygen demand. |
EVALUATION
- Client states feeling calmer
- Heart rate and breathing slow toward baseline
- Client describes the plan of care
Quick answers
What is the first thing the nurse should do for a client reporting chest pain?
Assess the client quickly and obtain a 12-lead ECG as ordered, ideally within 10 minutes.
When should nitroglycerin be held?
When systolic BP is low per protocol or the client has taken an erectile dysfunction drug recently, because both can cause severe hypotension.
For learning only. Individualize every care plan to your client, and follow your program, current guidelines, provider orders, and facility policy.