Download Nurse Practitioner CLINICAL PROTOCOL Chest Pain

Nurse Practitioner
CLINICAL PROTOCOL
Chest Pain
INTRODUCTION: Patients presenting with chest pain require rapid evaluation. Myocardial
ischaemia should be considered in all patients presenting with chest pain. Assessment of
pain type and referral, and response of pain to various interventions is important in
differentiating between cardiac and non-cardiac chest pain. If the pain is cardiac in nature it
is important to respond quickly to ensure the best possible outcome for the Pt.
DIFFERENTIAL DAIGNOSIS:
• CVS CAUSES; AMI, unstable angina, aortic dissection, aortic aneurysm, pericarditis,
aortic stenosis, mitral valve prolapse.
• RESP CAUSES; pulmonary embolism, pneumothorax, severe pneumonia.
• GI CAUSES; oesophageal spasm or rupture, gastric reflux, indigestion, perforated
peptic ulcer.
• Musculoskeletal causes.
• Trauma or neoplasm.
• Psychiatric causes.
CLINICAL PRACTICE GUIDELINE
Nurse
Practitioner
•
Scope
Chest pain responsive to protocols
outlined within this CP.
Medical
• Chest pain unresponsive to treatment
Practitioner
outlined within this CP.
+/• Evidence/suspicion of AMI or more
Nurse
serious cause of pain.
Practitioner
Initial Assessment and Interventions
Presenting
• Relevant past medical Hx and
History
medication history
• Known allergies
• Pt. describes pain as squeezing,
pressing, constricting, and heavy in
central chest, +/- radiating to left
arm, neck or jaw.
• Pt. may feel a “sense of impending
doom”.
Outcomes
Identify patients suitable for
NP clinical protocol. Refer
unsuitable pts. to current GP.
Identify patients not suitable
for NP CP and redirect to usual
GP care +/- ED
Outcomes
Identify patients not suitable
for NP CP and redirect to usual
GP care +/- ED
Nurse Practitioner
CLINICAL PROTOCOL
Chest Pain
Physical
examination
•
•
Primary survey – ABC
Vital signs (T, P, R, BP), ECG if
available. Signs of ST elevation –
refer GP/ED for thrombolysis.
• Assess pain: time of onset, position
of pain including any radiation,
description of pain, severity of pain,
length of time pain has been present,
frequency of pain episodes, what
were you doing when the pain
started, does anything make it better
or worse, is it reproducible by
palpation
• Any nausea, epigastric discomfort?
• Note any diaphoresis.
• Any SOB or dizziness
• Is the Pt. pale?
Be aware of atypical signs/symptoms:
• No chest pain, but pain related to
exertion or stress in the left arm or
jaw.
• Epigastric discomfort.
• Unexplained fatigue.
• Indigestion, belching.
• Dizziness
• Pain in the right arm.
• Confusion.
• Assess associated vascular risk
factors (eg strong family Hx).
Identify patients not suitable
for NP CP → exit CP and refer
to current GP.
Pain
assessment
Asses level of pain using appropriate pain
scale. Morphine 2.5 – 5mg IV then titrate to
effect if required (GP only).
Determine need for and type of
analgesia required.
Pathology
•
Imaging
•
Investigations
Troponin, FBC, U&E, CK, LFT’s
CXR if respiratory cause suspected.
Patient Education / Follow-up
Follow up
Verbal instruction to patient:
appointment
• Review appointment may be indicated
by pathology results; NP to contact
patient to schedule follow-up
Outcomes
Refer to GP for ongoing
management.
Diagnosis of cause of pain and
application of correct treatment
regime.
Outcomes
Ensure patient understands
problem, treatment and follow
up.
Nurse Practitioner
CLINICAL PROTOCOL
Chest Pain
appointment.
Patient
Education
Verbal instruction and patient information
handout if required and appropriate.
Patient understanding of the
problem, treatment and
measures which may reduce
the risk of ongoing
complications.
Medication
• Verbal/written instructions from NP/GP Ensure patient understands
problem, treatment and follow
instructions
up
Referrals
Referrals may be required for specific patient
Patients with problems outside
problems or as required to:
the NPs scope of practice are
• Physiotherapy
referred to appropriate health
• Drug and alcohol counsellor
care providers.
• Other problems outside of NP scope of
practice
Ensure appropriate
Certificates
• Absence from work certificates
• Certificate of attendance
documentation completed
Letter
• Copy of notes to GP / Specialist or
Ensure continuity of care and
acute care facility
referral to health care team
GP Æ hospital admission
Interpretation of results and management decisions
Outcome
All medications will be stored, labelled and dispensed in accordance with hospital policy and relevant legislation
Nurse
e Practition
ner
CLINICA
AL PROTO
OCOL
Ch
hest Pain
Inittial
manag
gement
path
hway
Reassu
ure Pt.
Plac
ce Pt. in an upright
u
positio
on
Give O2 2-4 L/nasal cannula
c
if available.
Assess vital signs (ECG if availa
able)
Assess ch
hest pain
If no resp
ponse to glyc
ceryl
trinitrate–
– refer to cu
urrent GP
for further advice and
d
ment.
managem
eriences a cardiac
c
If Pt. expe
arrest – commence
c
b
basic
life
support/a
advanced life
e support
as per fac
cility protoco
ol.
r
to
Documenttation and referral
current GP, transfer to
t nearest
cy departme
ent.
Emergenc
er sublingual glyceryl triniitrate as
Administe
prescrribed
Assess vittal signs
Iff no response
e after 5 mins
s
Repea
at sublingual glyceryl trinittrate
Assess vittal signs
Iff no response
e after 5 mins
s
Repea
at sublingual glyceryl trinittrate
Assess vittal signs
If pain is unresolv
ved after 20 mins
m
(3 doses of glyc
ceryl trinitrate
e)
CAL
LL 000 FOR AN
A AMBULANC
CE
Administer 300mgs Aspirin
n
R
Reassess
Pt. every
e
5 mins
Administer analg
gesia if requ
uired
y if necessa
ary
Maintain airway
C
Continue
to reassure
r
Pt..
Nurse Practitioner
CLINICAL PROTOCOL
Chest Pain
Goals of Treatment
• Relief of symptoms
•
Prevention of recurrence
•
Prevention of complications
Drug Formulary
FORMULARY
GLYCERYL TRINITRATE
ASPIRIN
Drug (generic name): Glyceryl Trinitrate
Drug (generic name): Aspirin
Dosage range: 400 mgs (spray) OR 600microgram (tablet)
Dosage range: 150 - 300mg
Route: oral (sublingual)
Route: oral
Frequency of administration: 5 minutely if pain persists
Frequency of administration: immediately
Duration of order: as required max of 3 metered doses, or 3
Duration of order: single dose
tablets (1800 micrograms).
Actions: immediate antiplatelet effect, produces complete
Actions: Venodialting effects, reduction in venous return and
inhibition of thromboxane-mediated platelet aggregation
preload to the heart therefore reducing myocardial oxygen
within 30 minutes.
requirement.
Indications for use: Acute chest pain with suspicion of acute
Indications for use: Prevention and treatment of angina,
coronary syndrome.
acute heart failure associated with MI.
Contraindications for use: Known NSAID hypersensitivity
Contraindications for use: hypovolaemia, raised ICP, G6PD
(esp. asthma).
deficiency (risk of haemolytic anaemia).
Adverse drug reactions: bleeding, GI upset,
Adverse drug reactions: headache, flushing, palpitations,
fainting, peripheral oedema. Rarely – rebound angina.
Unexpected
representation
NP Clinical
Practice
Evaluative strategies
Review Patient Notes. Full audit of clinical
events.
NP Clinical Practice/Medical Report Audit
Nurse Practitioner
CLINICAL PROTOCOL
Chest Pain
Key Terms
NP – Nurse Practitioner
CP – Clinical Protocol
GP – General Practitioner
S4 – Schedule of the drug administration
act
References
1. Australian Medicines handbook (internet). 2011, Nov. Accessed 2011 Dec 1 at
http://www.amh.net.au
2. etg complete (internet). Melbourne: Therapeutic Guidelines Limited; 2011 Nov.
Accessed 2011 Dec 1 at http://etg.tg.com.au/ref/ref
Authorship, Endorsement and acknowledgement
This CP was originally written by:
Reviewed and authorised by:
Carol Jones
Dr. Frank Reedman Jones
Nurse Practitioner
MBBCh, DCH, DRCOG, FRACGP, FACRRM
Murray Medical Centre Mandurah
Murray Medical Centre: Primary Care
Physician
We acknowledge the authorship and
input of :
Dr. Eileen Bristol
MBChB,MRCGP,DRCOG,FRACGP
Murray Medical Centre: Primary Care
Physician
Carol Jones
RN, RM, PGradDipNursePractitioner, NP
Nurse Practitioner
Date Written: November 2011
Review Date: November 2013