1 2 5 key

Nursing Practice
Review
Cardiology
Keywords: Chest pain/Assessment/
Coronary heart disease
●This
article has been double-blind
peer reviewed
Chest pain is a complex symptom with a variety of causes. It is essential that health
professionals have good communication skills to ensure an accurate diagnosis
Is chest pain always
an emergency?
In this article...
auses of chest pain
C
Tools used to assess chest pain
Case studies to illustrate chest pain assessment
Author Helen Gaunt is cardiac nurse
specialist, Rapid Access Chest Pain Clinic,
University Hospitals of Leicester Trust.
Abstract Gaunt H (2014) Is chest pain
always an emergency? Nursing Times; 110:
44, 12-14.
Chest pain is a complex symptom, which
has a number of underlying causes.
Accurate assessment is vital to ensure
patients receive appropriate and timely
care. This article provides an overview of
the causes of chest pain and key features
of the assessment process.
Alamy
I
n the UK around 80,000 people die of
coronary heart disease (CHD) each year
(Townsend, 2012). One of the signs of
CHD is chest pain, which 20-40% of
people experience at some time in their life
(Ruigomez et al, 2006). However, chest pain
is a complex symptom with a number of
causes, some of which are non-cardiac.
Careful assessment is required to ensure
patients receive appropriate management.
The National Institute for Health and Care
Excellence (2010) stresses the importance
of “accurate” and “fast” diagnoses of chest
pain, ensuring patients are treated appropriately and promptly.
In our Rapid Access Chest Pain Clinic we
see over 2,500 people each year with chest
discomfort; roughly half have symptoms
that are unlikely to be cardiac in origin.
These patients are discharged to their GP to
investigate alternative causes. Differential
diagnosis of chest pain is given in Table 1.
Causes of chest pain range from angina
and acute myocardial infarction (MI) to
more benign and self-limiting problems,
such as musculoskeletal pain, and gastrooesophageal symptoms such as heartburn
(Ebell, 2011).
Assessment
NICE (2010) recommends a structured
assessment using algorithms to ensure
high-risk patients are identified and treated
appropriately and promptly. It also highlights the “red flags” that those carrying out
the assessment should be aware of and suggests management plans, including:
» Raised biochemical markers;
» Electrocardiogram changes;
» Signs the patient is haemodynamically
unstable;
» Associated symptoms such as nausea
and vomiting, breathlessness or
marked sweating.
Albarran (2002) suggests nurses’ assessment of chest pain can be divided into:
» Diagnosis;
» Therapeutic care;
» Conveying humanistic concern;
» Improving and maintaining the
nurse–patient relationship;
» Accountability and legal implications.
Comprehensive assessment and history
taking is essential to ensure accurate diagnosis. Each episode of chest pain should be
taken on its individual merit, irrespective
of whether the patient has been assessed
for chest pain in the past (Zitkus et al, 2010).
Patients with chest pain do not always
fit into a typical pattern of symptoms, particularly when they are anxious. Pain must
be considered along with investigations
including ECG and observation of the
blood pressure, pulse, respiratory rate and
oxygen saturations.
Fass and Achem (2011) highlight that
patients with a diagnosis of non-cardiac
chest pain often have higher levels of anxiety and feel their symptoms are “less controllable” than those with a cardiac condition. It is important to listen carefully to
12 Nursing Times 29.10.14 / Vol 110 No 44 / www.nursingtimes.net
5 key
points
1
80,000 people
die of coronary
heart disease
each year
Chest pain is a
common
presenting
symptom in
primary care
There are
non-cardiac
causes of chest
pain
Accurate
assessment is
vital to ensure
correct
management
A variety of
assessment
tools are available
to assess chest
pain
2
3
4
5
fig 1. Levine’s sign
Nursing
Times.net
For articles on cardiology, go
to nursingtimes.net/cardiology
Table 1. differential diagnoses of chest pain
Diagnosis
Symptoms/characteristics
Myocardial infarction
● Severe, band-like, crushing, gripping, squeezing pain
● Sudden onset
● May be associated with shortness of breath, nausea,
sweating or dizziness
● Patients may also report a fear of impending doom
Angina
● Tightness, squeezing, ache or crushing pain that may
radiate to the neck, jaw, arms and through to the back
● Commonly occurring with exertion and usually relieved
within minutes of rest
● Often worse when exercising in colder weather or
after eating
Musculoskeletal chest
pain
● Can be severe at times
● Often a localised tenderness, which is made worse with
moving or twisting and tends not to be related to exertion
● Commonly reproduced or made worse by palpation over
areas of the chest wall
● Relieved by analgesics, such as non-steroidal antiinflammatory drugs
Gastro-oesophogeal
reflux disease
● Burning pain usually in the centre of the chest may
radiate through to the back and up to the throat
● May be associated with acid reflux
● Linked to food and posture
● Relieved by dietary changes, antacids or proton pump
inhibitors
Non-organic pain
● The patients may pinpoint localised areas of discomfort,
which may be left or right sided
● The symptoms are not usually linked to exertion
● Often related to anxiety and stress and occurs in
younger people, particularly when there is a family history
of heart disease
each patient’s description of their problem
during the initial assessment. This assessment should consider risk factors for CHD,
gastro-oesophageal reflux disease, musculoskeletal chest pain and past medical history. NICE (2010) recommends an initial
clinical assessment followed by diagnostic
tests if these are indicated. Rick factors for
CHD are outlined in Box 1.
It is essential to assess the impact of the
pain on patents’ lives. Ask them if they are
still able to work and continue with their
usual routine or whether they have modified it consciously or subconsciously.
A variety of tools can be used as part of a
chest pain assessment; selection is often
based on individual preference (Oriolo and
Albarran, 2010). As an example, mnemonics (Box 2) can be used to help guide
assessment.
The numerical visual analogue scale is
often used to assess pain. The patient is
asked to pick a number between 0 and 10,
where 0 = no pain and 10 = the worst pain
imaginable.This is typically used as an
adjunct to the assessment as it identifies
the pain as being whatever the patient says
it is (McCafferey, 1979) and, as such, is
highly subjective. Albarran (2002) suggests
that although pain scores are quick and
easy to use, they only measure intensity; in
addition, older people may struggle to use
them as they may find it difficult to quantify pain.
The use of open-ended questions, good
listening skills and acknowledging
patients’ concerns regarding their health
all help to obtain accurate information
from patients and enhance the nurse–
patient relationship (Albarran, 2002).
Reading patients’ description of their
condition back to them is a good way to
ensure the facts are accurate and allows the
opportunity for both parties to clarify any
misunderstandings.
Leicester is a large multicultural city
and many of our patients do not speak
English as a first language. Misunderstandings may occur with the words we
use to describe symptoms. For example,
we may say “in slight discomfort” but
some patients may describe their pain as
“slowly”, meaning a small amount. Access
to translators, along with good verbal and
Box 1. Risk factors for
Coronary Heart
disease
● Hypertension
● High cholesterol
● Diabetes
● Smoking
● Lack of exercise
● Overweight or obese
● Family history of coronary heart
disease
● Ethnic background, for example rates
of CHD in the UK are highest in South
Asian communities
non-verbal communication, is essential in
these circumstances.
Non-verbal cues
Assessment should not rely on verbal communication but should also take into
account non-verbal cues. When asked to
describe their chest pain people often use
hand movements to help illustrate their
symptoms. Patients with ischaemic chest
pain often place a clenched fist in the
middle of their chest to represent their
description of “gripping”. This is known as
Levine’s sign (Fig 1). Edmondstone (1995)
studied individuals admitted to coronary
care and found that if patients used the
Levine sign to describe their pain, there
was a 77% chance the pain was ischaemic.
Patients with pain associated with
oesophageal problems tended to point up
and down through the centre of their chest
(Edmondstone, 1995), while fingertip pinpointing to localised areas over the chest
wall is linked to musculoskeletal causes of
chest pain.
Case studies
Case study 1
Harry Brown* is 49 years old and usually fit
and well. He is anxious as his father had his
first MI at the same age and mentions this
repeatedly during the assessment. He has
no other risk factors for CHD.
Mr Brown presents with a history of
new-onset, upper-left-sided chest pain
after heavy gardening. The pain does not
radiate and there are no other symptoms.
The pain is almost constant, is worse when
he moves his left arm and is eased a little
with the help of regular paracetamol and
non-steroidal anti-inflammatory drugs.
Mr Brown rates the constant pain at 4/10
on the pain scale but says it can go up to 7
or 8 if it is particularly troublesome. The
pain is not associated with exertion. He
both feels and looks very anxious and worried. His blood pressure, pulse and
www.nursingtimes.net / Vol 110 No 44 / Nursing Times 29.10.14 13
Nursing Practice
Review
respirations are recorded, as is an ECG and
oxygen saturation levels.
Using the CHEST mnemonic (Box 3):
» C – Commenced in the past few weeks;
» H – Symptoms occurred after heavy
gardening, low risk for CHD;
» E – No other associated symptoms;
» S – Localised upper-left-sided chest
pain and no radiation of pain;
» T – Pain is almost constant.
After the assessment the most likely
cause of the pain is musculoskeletal. Mr
Brown requires no further cardiac assessment and is advised to continue with
simple pain relief, rest as able and to see
his GP if there is no sign of improvement.
Case study 2
Barbara Chaney* is 60 years old and woman
and reported a recent onset of chest discomfort over the past few months. She attended
her GP recently for an annual health check
and decided to mention it. A full history of
the complaint was obtained along with her
blood pressure, pulse, ECG results, oxygen
saturations and respiratory rate.
Ms Chaney says what she feels is not a
pain but more of an ache or tightness. The
discomfort is across the centre of her chest
and radiates up to her neck and jaw and,
on occasion, into her left arm and she
feels slightly short of breath. Symptoms
occur most days. She has noticed them
when she walks her dog and they usually
start as she walks up an incline. If she stops
for a few minutes the symptoms quickly
subside and she is able to continue
walking, albeit at a slower pace. She has
noticed these same symptoms when
climbing the stairs at home but she has
neither had pain at rest nor pain for prolonged periods.
Ms Chaney gave up smoking 25 years
ago and has type two diabetes, which is
controlled with diet. Her mother developed CHD at a similar age and died of an
MI aged 65 years. Her latest cholesterol
level was measured at 6mmol/L (5mmol/L
is considered normal but a level of
4mmol/L is recommended for cardiac
patients) (NHS Choices, 2013).
Using the PQRST mnemonic (Box 3):
» P – Pain always on exertion and relieved
within minutes of rest;
» Q – Quality of pain described as more of
an ache or tightness;
» R – Radiates to neck, jaw and arm;
» S – Symptoms occur across the centre
of her chest;
» T – Symptoms started a few months
previously and were initially not
particularly troublesome. However,
Ms Chaney has noticed that they
Box 2. Mnemonics used to guide assessment
CHEST
● C Commenced – When?
● H History – Is there evidence of risk factors for CHD or triggers?
● E Extra – Are there additional symptoms, that is nausea, shortness of breath?
● S Stays – Is it short lived? Does the pain radiate to the jaw, arms or throat?
● T Timing - How long does it last?
Source: Jones et al (2002)
PQRST
● P Provocation/palliative – What triggers the pain and what relieves the pain?
● Q Quality – Description: is it stabbing or sharp? How bad is it?
● R Radiation – Does the pain radiate to the shoulder arms or jaw?
● S Site – What is the exact site of the pain?
● T Timing – When did the pain start? Was onset sudden or gradual? Was it short
term or long lasting?
Source: Steadman (2010)
have increased in frequency.
On assessment the most likely cause of
her symptoms is angina. Ms Chaney is prescribed 75mg aspirin as an antiplatelet, a
beta-blocker to reduce her heart rate
and cardiac workload, and a statin to
help achieve a total cholesterol level of
4mmol/L or below. A glyceryl trinitrate
(GTN) spray is also prescribed to relieve
symptoms of pain. She is given advice
regarding pain and symptoms management and use of the GTN. Ms Chaney is
also referred to the cardiac rehabilitation
programme for ongoing support, exercise
and lifestyle advice.
Documentation
Clear, precise documentation of a chest
pain assessment is vital for the initial and
future management of patients presenting
with symptoms. Ensuring that care is consistently documented enables patients’
symptoms to be compared over time and
helps to identify any improvement or deterioration in symptoms.
Conclusion
Experiencing chest pain can be a frightening experiencing. The role of the cardiac
nurse specialist in assessing individuals
promptly and confidently, providing reassurance and education as support is vital.
It can take years to develop the skills and
ability to assess people well – chest pain
assessment is, at times, challenging and
complex. Assessing people who may find it
difficult to articulate their experiences, in
part due to anxiety and fears or because of
language barriers, means that nurses need
to quickly develop and build a trusting
relationship, eliciting clear, precise facts,
14 Nursing Times 29.10.14 / Vol 110 No 44 / www.nursingtimes.net
that will enable speedy, accurate and
appropriate treatment. NT
*Patients’ names have been changed.
References
Albarran J (2002) The language of chest pain.
Nursing Times; 98: 4, 38-41.
Townsend N (2012) Coronary Heart Disease
Statistics. London: British Heart Foundation. tinyurl.
com/BHF-stats-CHD
Ebell MH (2011) Evaluation of chest pain in primary
care patients. American Family Physician; 83: 5,
603-605.
Edmondstone WM (1995) Cardiac chest pain: does
body language help the diagnosis? The BMJ; 311:
1660-1661.
Fass R, Achem SR (2011) Noncardiac chest pain:
epidemiology, natural course and pathogenesis.
Journal of Neurogastroenterology and Motility; 17:
2, 110-123.
Jones G et al (2002) Emergency Nursing Care:
Principles and Practice. London: Greenwich
Medical Media.
McCafferey M (1979) Nursing Management of the
Patient with Pain. Philadelphia, PA: JB Lippincott.
NHS Choices (2013) Diagnosing High Cholesterol
- Getting a Cholesterol Test. tinyurl.com/
CHDcholesterol
National Institute for Health and Care Excellence
(2010) Chest Pain of Recent Onset: Assessment
and Diagnosis of Recent Onset Chest Pain or
Discomfort of Suspected Cardiac Origin. tinyurl.
com/NICECG95
Oriolo V, Albarran JW (2010) Assessment of acute
chest pain. British Journal Cardiac Nursing; 5: 12,
587-593.
Ruigomez A et al (2006) Chest pain in general
practice: incidence, comorbidity and mortality.
Family Practice; 23: 2, 167-174.
Steadman P (2010) Knowing when chest pain is an
emergency. Independent Nurse; 4: 19.
Tough J (2004) Assessment and treatment of
chest pain. Nursing Standard; 18: 37, 45-53.
Zitkus B (2010) Assessing chest pain accurately.
Nursing; 40: 1-6.
For more on this topic go online...
Factors in attendance at cardiac
rehabilitation
B
it.ly/NTCardiacRehabAttend