Comfort: Chest Pain
Comfort: Chest Pain
| (_)
Myocardial Infarction (_) Unstable Angina (_) Coronary Artery Disease (_) Chest Trauma (_) Stress Anxiety |
(_)
Musculoskeletal Disorders (_) Pulmonary, Myocardial contusion (_) Other:_____________________________ ____________________________________ ____________________________________ |
| Major:
(Must be present) |
(_) Person reports or demonstrates a discomfort. |
| Minor:
(May be present) |
(_)
Increased BP (_) Diaphoresis (_) Dilated pupils (_)
Restlessness (_) Facial mask of pain (_) Crying/moaning (_) Short of breath (_) Anxiety |
| Date & Sign. |
Plan and Outcome [Check those that apply] |
Target Date: |
Nursing Interventions [Check those that apply] |
Date Achieved: |
| The
patient will: (_) Verbalize relief/control of pain. (_) Verbalize causative factors associated with chest pain. (_) Other: |
(_)
Assess for causative factors asssociated:
(_) Assess characteristing of chest pain.
(_) Review history of previous pain experienced by patient and compare to current experience. (_) Instruct patient to report pain immediately. (_) Continuous EKG monitoring; note and record pattern during pain. Obtain STAT 12-lead EKG per policy for acute changes noted on continuous monitor. (_) Provide a quiet, restful environment. (_) As per physician order, administer IV analgesics in small increments until pain is relieved or maximum dose is achieved. Monitor BP during administration of pain meds. Assess pt. response to pain medication and notify physician if pain is not controlled or pt. experiences adverse reaction (decreased BP, HA, distress). (_) Administer nitroglycerine as ordered by physician. Monitor as stated above. (_) Titrate IV Nitro to achieve pain relief as ordered by physician. Monitor hemodynamic response to medication (BP, urine output). (_) Administer supplemental oxygen as ordered by physician. (_) Assist with ADL's to reduce cardiac stressors. (_) Assist in eliminating causative factors as identified by patient assessment. (_)
Other:________________ |
__________________________
Patient/Significant other signature
__________________________
RN signature
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