NursingSKL clinical tip
August 14, 2023
Retrosternal chest pain is a medical emergency. Potentially being the first person to assess a patient with this condition places a nurse in a critically important part of the health-care team as minutes can matter between life and death.
There are two very important things that must be considered when assessing a patient with chest pain:
- Are they very ill? To assess this, we need to answer a series of questions: what are the patient’s vital signs? Are they hypoxic? What is their blood pressure, pulse rate and rhythm? Patients with certain types of myocardial infarction may quickly become hemodynamically unstable, as can patients with aortic dissection and pulmonary emboli. Benign conditions such as chest wall pain and esophageal spasm will not cause hemodynamic instability.
- Is the chest pain of cardiac origin? The classic description of cardiac pain is that of a pressure (elephant sitting on the patient’s chest), which may be associated with radiation into the arm or jaw. Rarer presentations include indigestion, isolated shoulder pain and back pain. Other important symptoms suggestive of cardiac pain (these are so called, “anginal equivalents”) include: shortness of breath (also seen in pulmonary embolism), nausea and vomiting, fatigue, and lightheadedness.
This patient noted significant heaviness of their chest 15 minutes after having a one-minute episode of indigestion following playing basketball. The pain also radiated into the left arm. An ECG was performed in the ER which showed the presence of ST elevation in the anterior leads (see V2 and V3). The patient also had an elevation of their Troponin T — a protein that is elevated in myocardial ischemia. The patient was diagnosed with an STEMI (ST elevated myocardial infarction) and was treated with emergent balloon angioplasty and a stent.
Clinical tip: In any patient with chest pain, consider the possibility of myocardial infarction. Atypical histories of shoulder and back pain and indigestion may also be related to cardiac dysfunction.
In this video you will learn how various symptoms correlate with the location of myocardial ischemia.
This clinical tip was provided by NursingSKL, a collaborative initiative between leading doctors and nurses to improve nurses’ clinical skills. Go to nursingskl.com to find out more, meet the faculty, and try our free Practicum on Diabetes Care.
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