Pain Management of Central Chest Pain - Essay Example

Pain Management of Central Chest Pain of Patients in the Emergency Department Introduction Nursing staff working in the emergency setting frequently come across patients presenting with chest pain, many of which may be serious in nature. Although many of them are not serious in nature, the nursing care must target rapid resolution of the pain or measures to rapidly initiate care of these patients since acute chest pain in the accident and emergency setting have different meanings to the patients. Most often the meaning of such acute chest pain and the feelings associated with such pains when the patients face such symptoms are critical in that the patients suffer fear of death (Hamilton et al., 2008). This means these groups of patients need special support from the nursing professionals and measures to relieve these pains as soon as possible, at least in order to decrease these feelings. In order to be able to handle and manage these cases appropriately in the Emergency Department setting the nurses must be able to critically analyse the signs and symptoms of these patients on presentation. It is also expected that the nursing staff must be able to assess these patients in a structured manner in the least possible time frame since the risks associated with adult patients presenting with chest pain may be enormous. In some cases rapid and timely institution of interventions may impact the outcomes of care very favourably, while failure to stratify these risks and to appropriately assess these patients may lead to a defective and ineffective care plan leading to serious morbidity and mortality. In fact current research evidence suggests that nurses should be trained to acquire skills in appropriately assessing a patient and then reaching a provisional diagnosis that can be ruled out or supported by point of care protocols such as C-Troponin, CK-MB, and Pro-BNP so legitimate care may be instituted at the earliest. In this assignment, a problem-solving approach will be elicited in the context if emergency nursing care delivered to a group of patients with central chest pain during a recent placement of this writer, where nursing skills of assessment, planning, implementation, evaluation and documentation of care will be demonstrated (Hamer and McCallin, 2006). Moreover this account will also demonstrate how critical the nursing communication skill becomes in delivering an effective, standard, and competent care to these patients while working independently or through interprofessional collaboration. Throughout this assignment, there will be demonstration of the process of nursing diagnosis and management decision making through critical thinking on the basis of academic nursing knowledge, evidence from literature, and reflective practice, so a safe, efficient, standard care may be delivered. In short, this account will demonstrate whether this author has acquired the skills of safe and autonomous practice in an emergency scenario of acute central chest pain, both from the pathophysiological and psychosocial contexts that a group of such patients may suffer (Gibler et al., 2005). Practice Scenario This assignment is largely based on this nurses last placement in the Emergency Department, where during placement, this nurse came across many patients with different symptoms. Most of these patients presented acutely. This means they had sudden onset of symptoms. Out of these patients, for this assignment, as the author recollects, the cases of four patients presenting with acute retrosternal chest pain will be dealt with. This group of patients, although they presented in different time frames have an equal mix of sex, two males and two females. The males were aged between 65-82, and the females were aged between 68-85. They have been grouped together because they all presented with similar symptoms of retrosternal chest pain. When interrogated in the triage they stated that the pain was of high intensity. When it began, it was located centrally and retrosternally, of crushing nature, and was noted to radiate to the back of the chest. The initial pain assessment was done by the paramedics using a visual analogue scale for pain, and all of them were given morphine while in the ambulance. In the Emergency Department, these patients were handed over to the mentor, and this nurse was assisting the mentor and the senior staff to get a detailed history from all of these patients and documenting them. This was mainly necessary to establish the accurate and baseline history for the doctors in case these were necessary for further care. Moreover, the most appropriate immediate treatment can be given with the objective of adequate pain management (Forslund et al., 2005). While assessing them, the extent of pain relief with the intervention would be assessed so the response to treatment and outcome of care can be evaluated. With the history, it was evident that all patients did not have a prior history of similar chest pain. Their social history did not suggest any particularly relevant fact to these pain episodes. Both the males and one of the women were married. The other woman was a widow and lived alone in a warden controlled house. All these patients had their family members close by. The family history did not reveal any positive family history of similar or identical chest pain. This assignment will concentrate on the immediate and remote pain management strategies as a part of the care process. The identities and the demographic details of these patients will remain undisclosed for ethical reasons and to demonstrate compliance to the nursing standards of care. Common Factors Chest pain is one of the most common challenges for healthcare professionals in the emergency department. There may be many reasons for this, but most common are the organs involving chest and abdomen, most likely being the chest. However, depending on the organ involved, the prognosis may range from benign to life-threatening. When faced with such conditions, it is important to recognise potentially life-threatening conditions and more important is to ensure pain relief. Depending on these factors decisions to referral to an emergency physician, admission to hospital, tests, procedures, and vigorous management are made, and these relate to the anxiety of the patients and their families (Elder et al., 2006). Among the most dreaded causes of central chest pain are myocardial ischaemia or injury from infarction. This occurs as a result of critical deficit in oxygen supply to the myocardium or heart muscles in contrast to the metabolic demand. Obviously there could be a mismatch resulting from relative deficiency of available oxygen due to deficient supply, rise in demand, or both. Academic knowledge suggests that the most common underlying cause of myocardial ischemia is obstruction of coronary arteries by a process called atherosclerosis leading to critical narrowing of a segment of these arteries. Even with physical or emotional exertion of any kind, the adrenergic stimulation to the heart muscles will cause increased activity, hence increased oxygen demand. The critical fall in oxygen supply to the cardiac muscles would lead to this type of pain where it is described as a visceral discomfort of the type of heaviness, pressure or squeezing (Singer et al., 2005). In some cases, this is just a vague sense of anxiety. The location of angina pectoris is usually retrosternal; most patients do not localize the pain to any small area. The discomfort may radiate to the neck, jaw, teeth, arms, or shoulders, reflecting the common origin in the posterior horn of the spinal cord of sensory neurons supplying the heart and these areas. Some patients present with aching in sites of radiated pain as their only symptoms of ischemia. Occasional patients report epigastric distress with ischemic episodes. Less common is radiation to below the umbilicus or to the back. These episodes can be precipitated by any physiologic or psychological stress that induces tachycardia. Most myocardial perfusion occurs during diastole, when there is minimal pressure opposing coronary artery flow from within the left ventricle. Since tachycardia decreases the percentage of the time in which the heart is in diastole, it decreases myocardial perfusion (Fagring et al., 2005). This constellation of symptoms is known as angina, and the most widely accepted cause is atherosclerosis resulting in luminal narrowing of the artery. The most severe form may lead to myocardial infarction which in turn results from acute obstruction of the coronary arteries due to thrombotic or embolic occlusion of the lumen leading to critical reduction in blood supply to a relevant segment of the coronary arteries. Patients judged to be at intermediate or high likelihood of significant CAD are often hospitalized for further evaluation and therapeutic intervention. The more serious varieties of pain symptoms are known to have a more prolonged duration of pain with a heightened intensity. Sometimes, the onset of these symptoms may occur with the patient at rest or even awaken the patient from sleep. As many as 10% of patients who present to emergency departments with acute chest pain have panic disorder or other emotional conditions. The symptoms in these populations are highly variable, but frequently the discomfort is described as visceral tightness or aching that lasts more than 30 min. Whatever may be the cause, this type of pain has serious prognostic importance due to the fact that myocardial infarction may be lethal. Due to this reason, a patient with such pain must be thoroughly evaluated, sometimes needing admission and observation and assessment using other available specific investigation of the cause (Goodacre et al., 2007). Nursing Assessment Nursing assessment of such patients includes many parameters, but in the Emergency Department scenario, the main focus should be on pain management. While attempting to manage pain, it is important to assess the history of the pain in a structured manner. The characteristic substernal chest pain is more of a crushing heaviness. The patients described this pain with different terms such as squeezing, aching, burning, choking, strangling, and/or cramping pain. With all the patients, the pain was between mild to severe, and there was a history of gradual buildup of pain with exertion. In two of the patients there was a history of gradual fading of pain. There was no associated history of numbness or weakness in arms, wrists, and hands (Swap and Nagurn, 2005). In these patients, when asked about the exact location of the pain, three of them made a fist over the site of the pain. The mentor told this is called positive Levine sign which indicates diffuse and deep visceral pain. Only one patient located the pain with a pointed finger. Two of them indicated that there was some radiation of the pain to the arms, and the other two indicated that the pain radiated to the back, anatomically which was posterior interscapular area, more oriented towards the left. All of them correlated the pain with some exertion, and the pain built up from there (Allison et al., 2000). This description might point to the common origin of the pain stimulus in the posterior horn of spinal cord sensory neurons that could have supplied the heart and the adjacent areas. Emotional stress or any other exertion leads to the pain in susceptible patients due to the fact that both these conditions lead to tachycardia. Tachycardia is known to reduce the duration of the diastole, and this may cause less perfusion of the coronary arteries since coronary arteries are known to receive their supply of blood during diastole. Pain management thus becomes very important part of the care, specially when delivered by the nurses since pain also produces emotional exertion and tachycardia, further enhancing chances of progressive ischemia leading to infarction (Mitka, 2005). Successful pain management depends on effective pain assessment. The nursing pain assessment classically occurs through the PQRST format. All these questions were asked to this group of patients. From the discussion it was evident that the interrogation of these patients happened in order to understand and document the position, provocative factors, quality and intensity, radiation, relieving factors, severity, associated symptoms, and timing of the pain. From the discussion about pathophysiology (Cross et al., 2007), it is evident that all these questions were very relevant in order to establish the possible aetiology of the pain in this group of patients. It was apparent that initiated management in the emergency room setting could cause relief of pain in two patients, while the other two did not show any sign of relief, and with discussion with the attending emergency department physician, following some baseline emergency room investigation, were decided to be admitted to the hospital for further investigation, observation, and treatment (Hitchcock et al., 2003). While doing this assessment, even though main aim was to attend the pain, a thorough evaluation of the pain symptoms is needed. To be able to arrive at a complete care plan, it is also important to gather information whether nitroglycerin treatment is effective in reducing the pain. This is more of a rough test about the cardiac origin of the pain. Moreover an assessment of the time needed to achieve relief may indicate the severity of the pain and may be correlated to the severity of the pain and hence the coronary artery disease that may be causing the pain (Forslund et al., 2008). Although it can be argued that pain is a subjective symptom and assessment is done usually through a visual analogue scale, the intensity of the pain may fail to correlate with the severity of the coronary artery lesions, the answers to these questions may form a logical basis of the management plan. It is also important to assess the risk factors for these patients, the responses to the angina, and the patients and family’s understanding of the diagnosis, and their emotional response to the diagnosis (Taylor et al., 2004). When the nursing diagnoses were framed for these patients, it transpired that the issues were not only chest pain due to possible coronary artery disease. All patients were going through the pain and fear of impending death since in their opinion, loss of blood supply to the heart meant impending doom. Moreover, there were risk factors associated with their profile, which needed to be attended to. Above all in order to get the most effective care outcome, the patients needed to understand their disease process (Speake et al., 2003). The initial history taking and examination was sufficient to build a rapport with these patients. When they were assured, the pain suspected to be arising from myocardial ischemia, it was decided that before going ahead with other and more focused assessment, all patients would be given a dose of sublingual nitroglycerin, and through observation of response to nitroglycerin, further course of action will be determined. As has been highlighted earlier, there is also an emotional element of this pain. Nitroglycerin is known to relieve most of the anginal pain episodes. With relief of pain and assurance, cooperation, health education, and other necessary investigations could be facilitated. Unfortunately, two patients did not respond to nitroglycerin. Therefore, it was necessary to subject them to investigations of electrocardiogram, blood tests of hemoglobin, blood sugars, coagulation profile, and oxygen saturation were important (Kelly, 2000). Those who had relief from initial nitroglycerin did not show any changes in these tests. However, those who did not demonstrate any pain relief had low hemoglobin, elevated blood sugars, and in ECG they demonstrated left ventricular hypertrophy and ST-T segment elevation. As a student this author did not know the exact implications of ST-T elevation, and the mentor suggested that the serious nature of the pain should be communicated to the patients, families, and the emergency room physician (Tough, 2004). This author approached the emergency room physician to have a check up and decide further management. This was a collaborative practice and was essential in this situation. While these patients waited for the doctor to come, it was prudent to treat the hypoxia, since a hypoxic state may further aggravate the possible infarction. The patients were started with 100% 15 L oxygen through non-rebreather mask, and their oxygen saturations normalised in no time (Heath et al., 2003). These patients had associated symptoms of nausea and diaphoresis. They were very anxious. They appeared pale, were feeling short of breath, were hypertensive, and were moderately tachycardic. The vital sign examinations were recorded. The pain assessment was frequent, and in a visual analogue scale the pains were rated by these patients to be 7 to 8. The assessment depended not only verbal cues but also non-verbal indications such as facial expression and gestures of the hand pointing to the pain. It is to be remembered that this cannot be an absolute scale of assessment due to the fact that sometimes pain of myocardial infarction is a sensation, may not clearly be a pain per se. While the patient waited, it was necessary to evaluate the pain frequently to demonstrate relief or aggravation of pain based on patients’ self report (Harvey, 2004). Once their diagnoses were confirmed by the physician, these patients were decided to be admitted. However, this took some time. Continued pain would produce more emotional stress and anxiety, and adequate pain relief would be necessary (Fagring et al., 2007). Nitroglycerin is known to dilate coronary vessels and in cases of angina, it produces adequate pain relief in ischemic patients. When the pain is irreversible with rest and nitroglycerin, as in the cases of two patients admitted, it was necessary to administer diamorphone. These drugs bind to opioids receptor sites, prevent release of neurotransmitters, and thus pain impulse transmission through the C fibres are prohibited. It was a controlled substance, and thus two nurses verified the dosage and the drug to reduce errors and overdosage. The sign of the doctor was verified, and an intravenous route was used to administer the drug through the cannula through which an intravenous fluid was running. Control drug book was signed to document appropriate administration. Although vomiting was a reported adverse effect of diamorphone, an antiemetic drug ondansetron was administered for antiemetic cover. It has been advised that administration of analgesic must be adequate and regular based on pain assessment; however, there may be a lapse in this area due to heavy workload in the emergency department where nurses may not be able to attend to a single patient in a dedicated manner. In this case, the case load was even for this nurse, since both these patients fortunately presented in a single day, and the nurse was assigned to the care of both these patients (Katz et al., 2006). Conclusion This disease produces symptoms and complications depending on the location and degree of narrowing of the arterial lumen, thrombus formation, and obstruction of blood flow to the myocardium. This impediment of blood supply may deprive the muscle cells of oxygen needed for their survival. Symptomatically, this leads to chest pain that is brought about by myocardial ischemia, and when chest pain is the prime presenting symptom, there is necessarily significant coronary atherosclerosis. Thus the intensity of the pain may be an important marker of reversibility of hypoxemic insult to the myocardium. If the pain intensity is more and if the pain is not reversible, it may lead to irreversible damage and death of myocardial cells, or MI. 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