patient care report example chest pain

What should I look for in a chest pain assessment?

You must be able to quickly assess for any primary life-threatening conditions, and also evaluate for any secondary underlying cause that could have brought on the initial chest pain. Often, resolving the aggravating cause will decrease the acuity of the initial complaint or condition.

Should clinicians evaluate each complaint of chest pain as if it's new?

This case shows that clinicians must always evaluate each complaint of chest pain as if it were new. Additionally, patients who complain of chest pain won't always have the expected signs and symptoms.

What should I do if my patient has chest pain?

When your patient has chest pain, you'll need to use your assessment skills to determine whether the patient is having an acute MI or some other life-threatening illness.

What is a patient care report?

A patient care report is a document written by medical professionals to report about the patient’s wellbeing, care and status. This document consists of the result of the assessment and the evaluation of the patient being done by the EMTs or the EMS.

How do you write a patient care report?

There are seven elements (at a minimum) that we have identified as essential components to documenting a well written and complete narrative.Dispatch & Response Summary. ... Scene Summary. ... HPI/Physical Exam. ... Interventions. ... Status Change. ... Safety Summary. ... Disposition.

What is included in a patient care report?

The primary purpose of the Patient Care Report (PCR) is to document all care and pertinent patient information as well as serving as a data collection tool. The documentation included on the PCR provides vital information, which is necessary for continued care at the hospital.

What do you do when a patient complains of chest pain?

If you or someone else may be having a heart attack, follow these first-aid steps:Call 911 or emergency medical assistance. ... Chew aspirin. ... Take nitroglycerin, if prescribed. ... Begin CPR on the person having a heart attack.More items...

How do you assess for chest pain?

Some of the first tests a health care provider may order when evaluating chest pain include:Electrocardiogram (ECG or EKG). This quick test measures the electrical activity of the heart. ... Blood tests. ... Chest X-ray. ... Computerized tomography (CT) scan.

How do you write a proper PCR?

The following five easy tips can help you write a better PCR:Be specific. ... Paint a picture of the call. ... Do not fall into checkbox laziness. ... Complete the PCR as soon as possible after a call. ... Proofread, proofread, proofread.

What is the minimum data set in a patient care report?

The Minimum Data Set (MDS) is part of a federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process entails a comprehensive, standardized assessment of each resident's functional capabilities and health needs.

What is the nursing diagnosis for chest pain?

Chest Pain also called Angina is a medical condition which involves chest pain due to the decrease in the blood supply to the heart. It is one of the definitive symptoms of coronary heart disease, and can also be a symptom for other cardiac issues.

What should a nurse do if patient has chest pain?

Nursing ManagementManage chest pain.Bed rest.Provide oxygen.Administer aspirin and nitroglycerin.Place patient with head of the bed elevated at 45 degrees.Make patient comfortable.Hook up to monitor.Check vitals.More items...•

What questions should I ask a patient with chest pain?

Questions aimed at identifying the patient with possible ACS:Where is your pain? (location)Does it go anywhere else? (radiation)When did it start? (onset)How long has it lasted? (duration)How bad is it? (severity on pain scale)Does anything make it better or worse?Have you taken any medication to relieve it?More items...

How would you describe chest pain?

This can feel like a squeezing, tightness, pressure, constriction, strangling, burning, heartburn, fullness in the chest, band-like sensation, knot in the center of the chest, ache, heavy weight on the chest, or a bra that is too tight. People with pain that is not angina often describe their pain as sharp or stabbing.

What are some of the causes of chest pain in patients?

What are the most common causes of chest pain?Heart attack. ... Coronary artery disease. ... Coronary artery dissection. ... Pericarditis. ... Hypertrophic cardiomyopathy. ... Aortic dissection. ... Aortic aneurysm. ... Mitral valve prolapse.More items...•

What are the causes of chest pain?

Possible causes of chest painMuscle strain. Inflammation of the muscles and tendons around the ribs can result in persistent chest pain. ... Injured ribs. ... Peptic ulcers. ... Gastroesophageal reflux disease (GERD) ... Asthma. ... Collapsed lung. ... Costochondritis. ... Hiatal hernia.More items...

What is a patient care report?

A patient care report is a document made mostly by the EMS or EMTs. This documented report is done after getting the call. This consists of the inf...

What should not be written in a patient care report?

What should be avoided in a patient care report is making up the information that is not true to the patient. This is why you have to be very caref...

Who is in charge of reading the patient care report?

The person or the people who will be reading the report are mostly medical authorities. When you are going to be passing this kind of report, make...

What was the Medic 1 response to above location?

(Location): Medic 1 responded to above location on a report of a 62 y.o. male c/o of chest pain. Upon arrival, pt presented sitting in a chair attended by first responder. Pt appeared pale and having difficulty breathing.

What happens if everyone is thinking alike?

If everybody is thinking alike, then somebody isn't thinking.

Does the patient respond to questions?

Patient does not respond to questions, but crew is informed by family that patient is deaf. Per family, the patient has been "sick" today and after consulting with the patient's doctor, they wish the patient to be transported to HospitalA for treatment.

Is PT allergic to shellfish?

PT has a sensitivity to Morphine Sulfate and is allergic to shellfish. PT has been complaint with his medication, according to his wife. PTs last meal was a chicken breast and rice. Upon our arrival PT was found sitting on the couch, in a high state of anxiety due to his flooded basement.

What causes fluid overload in the lungs?

Another nursing problem is fluid overload. Some patients with the pulmonary congestion develop this rapidly because of a sudden increase in left ventricular (LV) filling pressures caused by conditions such as acute myocardial ischaemia or uncontrolled hypertension (Pellicori, 2015). (‘flash’ pulmonary oedema). Pulmonary oedema, (PO) the build up of fluid on the lungs is associated with coronary heart disease. Conditions such a LVH, congestive heart disease or a MI could lower the ability of the ventricles of the heart to circulate blood through the blood capillary network in the lungs. The stagnation of blood in this network causes build up of pressure that forced blood fluid into the interstitial tissue of lungs (Pellicori, 2015).

How to treat PO?

A possible nursing intervention associated with onset of PO is to supply adequate oxygen to the patient, usually by an appropriate mask . This will improve the supply of oxygen to the heart and assist in gas exchange affected by the presence of fluid in the lungs (Pellicori, 2015). The nurse needs to monitor the supply of oxygen at an appropriate continuous rate and that the patient is fitted correctly with the mask (Pellicori, 2015). A medication such as frusemide may be prescribed as this not only treats the pulmonary oedema build up directly but also acts to relieve hypertension. This could be given by injection or possibly as an IV. Nursing staff could be responsible for the administration of injections at the right times with correct dosage or set up and monitoring of the IV drip, replacing bags as needed. Nurses also should be vigilant as to the possibility of side affects such as ringing in the ear, loss of hearing and light headiness known to be associated with frusemide (Sanmuganathan, 2001).

What is PO in pulmonary oedema?

Pulmonary oedema, (PO) the build up of fluid on the lungs is associated with coronary heart disease. Conditions such a LVH, congestive heart disease or a MI could lower the ability of the ventricles of the heart to circulate blood through the blood capillary network in the lungs.

Why is salt bad for you?

The reason for this is that high salt levels can increase the risk of cardiac events such as MI. It has been known for quite some time that high salt intake leads to high blood pressure that in turn is a major direct cause of coronary heart disease, (Strazullo, D’Elia, Kandale & Cappuccio, 2009).

What is the cardiovascular system?

The cardiovascular system responsible for the transport of blood throughout the body, consists of the heart, blood and vessels which including arteries, capillaries and veins (Williams & Bradford, 2015). The coronary arteries are vital to the hearts function as they deliver a constant supply of blood to heart muscle ( Williams & Bradford, 2015 ). Coronary circulation provides oxygenated blood throughout the myocardium and returns deoxygenated blood to the right atrium via the coronary sinus (Williams & Bradford, 2015). The two main coronary arteries are the first branches of the ascending aorta, just outside the left ventricle. The left coronary artery divided into the anterior descending and the circumflex arteries providing blood for the left atrium and the left. The right coronary artery supplies the ventricle and part of the posterior wall of the left ventricle as well as the atrioventricular node of the cardiac conduction system (deWit, 2013). The thin walled small diameter of the coronary arteries makes them vulnerable to the accumulation of fatty plaque build-up that can significantly restrict blood flow through the arteries leading to rupture of the fragile walls a process known as arteriosclerosis, involving clotting causing obstruction of a coronary artery (deWit, 2013).

What is the condition that causes angina pectoris?

Angina pectoris occurs when one or more of the heart arteries are narrowed or blocked a condition called ischemia (Cassar el at 2009). Unstable angina caused by acute coronary syndrome, produces unexpected chest pain, normally commencing during rest, (Fladseth el at, 2018). This arises due to ischemia.

What is the condition that causes chest pain?

This can also manifest in the shoulders, arms, jaws or back. Angina pectoris occurs when one or more of the heart arteries are narrowed or blocked a condition called ischemia (Cassar el at 2009). Unstable angina caused by acute coronary syndrome, produces unexpected chest pain, normally commencing during rest, (Fladseth el at, 2018). This arises due to ischemia.

Why does referred pain occur?

Referred pain usually occurs because both the nerves (afferent fibers) of the viscera and the somatic region enter the spinal cord at the same level. 6 Thus, the patient who has both visceral and somatic pain could have a sharper and more localized sensation of the pain in the chest region.

What is visceral pain?

The decreased blood flow through an occluded or partially occluded coronary artery resulting in the sensation of heaviness or crushing-type feeling in the chest is an example of visceral pain. Somatic pain, on the other hand, is described as sharp, piercing, and specific to a local area.

What is chest pain assessment?

When your patient has chest pain, you'll need to use your assessment skills to determine whether the patient is having an acute MI or some other life-threatening illness. By knowing the signs and symptoms of the various causes for chest pain, you can quickly assess and determine whether the patient has a life-threatening condition and provide appropriate and possibly lifesaving care.

What are the findings on a 12-lead ECG that are considered indicative of an acute MI?

Findings on a 12-lead ECG that are considered indicative of an acute MI include ST-segment elevation, Q waves, and possibly a conduction defect. 14

What is nociceptive pain?

Nociceptive pain arises from specific pain receptors and is classified as somatic or visceral in nature. Visceral pain originates from specific internal organs, such as the heart, liver, bowels, or bladder. The pain receptors in the viscera react to stretch, inflammation, and ischemia.

How many people had chest pain in 2006?

According to the National Health Statistics Reports on Ambulatory Medical Care Utilization Estimates for 2006, 9 million patients had a complaint of chest pain and more than 2.5 million went to a primary care office for diagnosis and treatment. The data also revealed a decrease in the number of visits to ambulatory care settings for chest pain, from 0.9% in 2005 to 0.7% in 2006. 1

Is myocardial infarction a somatic or visceral pain?

Cardiac pain may have both a visceral and a somatic component or neither (silent myocardial infarction [MI]). Referred pain usually occurs because both the nerves (afferent fibers) of the viscera and the somatic region enter the spinal cord at the same level. 6 Thus, the patient who has both visceral and somatic pain could have a sharper and more localized sensation of the pain in the chest region. The patient with a silent MI may only experience symptoms of gastric fullness or a heaviness in the chest. This occurs due to a miscommunication to the brain regarding the pain experienced and often provides an additional challenge to the clinician evaluating the patient. However, asking pertinent questions regarding the type of pain the patient is experiencing, performing a thorough objective exam and obtaining the appropriate diagnostic tests will help lead to the correct diagnosis in the initial evaluation of a patient with chest pain.