Chest Pain (Adult Inpatient)

Clinical Description

Care of the hospitalized patient experiencing chest discomfort or pain.

Key Information

Myocardial ischemia should always be considered as the cause of chest pain until proven otherwise when risk or suspicion of heart disease is present. Severity of chest pain has little association with seriousness of the cause.

Life-threatening causes of chest pain must be initially evaluated, such as acute coronary syndrome, pulmonary embolism, acute myocardial infarction, tension pneumothorax or aortic dissection. When cardiac cause is identified, timely treatment must be initiated.

Women, patients with diabetes and older adults frequently have unique presentations of ischemic cardiac pain.

Other causes of chest pain may include muscle strain, stomach or esophageal source (e.g., gastroesophageal reflux disease), pericarditis, pneumonia, costochondritis, pancreatitis, herpes zoster infection and cocaine use.

Clinical Goals

By transition of care

A. The patient will achieve the following goals:

Resolution of Chest Pain Symptoms

B. Patient, family or significant other will teach back or demonstrate education topics and points:

Education: Overview
Education: Self Management
Education: When to Seek Medical Attention

Correlate Health Status

Correlate health status to:
- history, comorbidity
- age, developmental level
- sex, gender identity
- baseline assessment data
- physiologic status
- response to medication and interventions
- psychosocial status, social determinants of health
- barriers to accessing care and services
- health literacy
- cultural and spiritual preferences
- safety risks
- family interaction
- plan for transition of care

Chest Pain

Signs/Symptoms/Presentation

chest heaviness
complaint of chest pain, pressure
diaphoresis
discomfort in arm, neck or jaw
fatigue
indigestion
nausea and vomiting
pain frequency intermittent or constant
pain with radiation
palpitations
shortness of breath

Vital Signs

heart rate increased or decreased
respiratory rate increased

Problem Intervention

Manage Acute Chest Pain

Note pain quality, characteristics, location, duration and associated signs and symptoms that may include diaphoresis, radiation, nausea and vomiting; assess aggravating and relieving factors.
Reassess pain frequently to determine effect of activity and interventions; use a consistent pain scale.
Prepare patient for diagnostic testing to determine pain source that may include an electrocardiogram, biochemical markers, computed tomography or chest x-ray.
Provide oxygen therapy judiciously if hypoxemia is present.
Anticipate aspirin administration, if not contraindicated.
Titrate medication in response to patient status; minimize the amount of medication needed to control symptoms.

Associated Documentation

Chest Pain Intervention

Education

CPG-Specific Education Topics

Overview

risk factors
signs/symptoms

Self Management

activity
provider follow-up

When to Seek Medical Attention

unresolved/worsening symptoms

General Education Topics

General Education

admission, transition of care
orientation to care setting, routine
advance care planning
diagnostic tests/procedures
diet modification
opioid medication management
oral health
medication management
pain assessment process
safe medication disposal
tobacco use, smoke exposure
treatment plan

Safety Education

call light use
equipment/home supplies
fall prevention
harm prevention
infection prevention
MDRO (multidrug-resistant organism) care
personal health information
resources for support

References

Allardet-Servent, J.; Sicard, G.; Metz, V.; Chiche, L. Benefits and risks of oxygen therapy during acute medical illness: Just a matter of dose! . 2019;40(10) doi:10.1016/j.revmed.2019.04.003 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
Arslan, M.; Dedic, A.; Boersma, E.; Dubois, E. A. Serial high-sensitivity cardiac troponin T measurements to rule out acute myocardial infarction and a single high baseline measurement for swift rule-in: A systematic review and meta-analysis. European Heart Journal: Acute Cardiovascular Care. 2019; doi:10.1177/2048872618819421 Source[Metasynthesis,Meta-analysis,Systematic Review]
Burgstaller, J. M.; Jenni, B. F.; Steurer, J.; Held, U.; Wertli, M. M. Treatment efficacy for non-cardiovascular chest pain: A systematic review and meta-analysis. PLoS One. 2014;9(8), e104722. [Metasynthesis,Meta-analysis,Systematic Review]
Hammond, B. B.; Zimmermann, P. G. (2013). Sheehy's manual of emergency care. St. Louis: Mosby, Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
Marx, J. A.; Hockberger, R. S.; Walls, R. M. (2018). Rosen's emergency medicine. Philadelphia: Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
O'Driscoll, B. R.; Howard, L. S.; Earis, J.; Mak, V.; British Thoracic Society Emergency Oxygen Guideline Group. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017, Jun;72(Suppl 1), ii1-ii90. [Quality Measures,Clinical Practice Guidelines]
Skinner, J. S.; Smeeth, L.; Kendall, J. M.; Adams, P. C.; Chest Pain Guideline Development Group. Chest pain of recent onset: Assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. Heart. 2010;96(12), 974-978. doi:10.1136/hrt.2009.190066 [Quality Measures,Clinical Practice Guidelines]
Urden, L. D.; Stacy, K. M.; Lough, M. E. (2018). Critical care nursing: Diagnosis and management. St. Louis: Mosby, Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]

Disclaimer

Clinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Care should always be individualized by adding patient specific information to the Plan of Care.