Apatient rings the nurse call bell and complains of chest pain. what will you do and why ? ( include specific clinical nursing assessments you will perform)

While there are a number reasons for a chest pain to be experienced, it is always safe to assume that it is cardiac in nature until proven otherwise to avoid potential life threatening conditions (like AMI).

CHEST PAIN ASSESSMENT  should include:

1.       Description of the pain (sharp, dull, crushing, stabbing) and exact location of the pain. The patient also should be interviewed if the pain radiate to other areas.

Pain associated with AMI is usually described as "constrictin" or crushing in the middle/upper substernal region that usually radiate to the anterior chest, shoulders and arms.

2.       Provoking factors  such as activity and position that makes the pain worse.

Chest pain caused by AMI tends to change with repositioning. Pain that improves with repositioning may be caused by pericarditis, pleuritic and musculoskeletal issues.

3.       Asking the patient to rate the severity of pain from 0-10 ( 0 being absent and ten the worst pain), and taking note of other accompanying symptoms.

AMI can also present with accompanying symptoms such as nausea, vomiting, diaphoresis, dizziness, hypotension.

4.       Time the duration of the pain. Angina typically lasts for 2-5 minutes (can last up to 30 minutes).

Inform the physician of you findings ( especially if significant for emergency care) so tests can be ordered, carried out and medications can be ascertained.

answer(d) call 911;

answer: b. complete secondary assessment (detailed physical exam).

after you finished the primary assessment, you must proceed with the assessment by performing a complete detailed physical examination.

this secondary assessment includes a focused on patient’s history, vital signs and a specific and rapid examination of the entire body especially on the injuries acquired from the motor vehicle accident and the patient’s medical complaint.