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
Scope Outcomes
Nurse
Practitioner
Chest pain responsive to protocols
outlined within this CP.

Identify patients suitable for
NP clinical protocol. Refer
unsuitable pts. to current GP.
Medical
Practitioner
+/-
Nurse
Practitioner
Chest pain unresponsive to treatment
outlined within this CP.
Evidence/suspicion of AMI or more
serious cause of pain.
Identify patients not suitable
for NP CP and redirect to usual
GP care +/- ED
Initial Assessment and Interventions Outcomes
Presenting
History
Relevant past medical Hx and
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.
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.

Investigations Outcomes
Pathology Troponin, FBC, U&E, CK, LFTs Refer to GP for ongoing
management.
Imaging CXR if respiratory cause suspected. Diagnosis of cause of pain and
application of correct treatment
regime.
Patient Education / Follow-up Outcomes
Follow up
appointment
Verbal instruction to patient:
Review appointment may be indicated
by pathology results; NP to contact
patient to schedule follow-up
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
instructions
Verbal/written instructions from NP/GP

Ensure patient understands
problem, treatment and follow
up
Referrals Referrals may be required for specific patient
problems or as required to:
Physiotherapy
Drug and alcohol counsellor
Other problems outside of NP scope of
practice
Patients with problems outside
the NPs scope of practice are
referred to appropriate health
care providers.
Certificates Absence from work certificates
Certificate of attendance
Ensure appropriate
documentation completed
Letter Copy of notes to GP / Specialist or
acute care facility
Ensure continuity of care and
referral to health care team
GP 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
Init
manag
path
tial
gement
hway
Plac
Give O2
Asses
Administe
If
Repea
If
Repea
If pai
(3
CAL
A
R
Admi
Mai
C
Nurse
CLINICA
Ch
Reassu
ce Pt. in an u
2-4 L/nasal c
s vital signs
Assess ch
er sublingual
prescr
Assess vit
f no response
at sublingual
Assess vit
f no response
at sublingual
Assess vit
n is unresolv
doses of glyc
LL 000 FOR A
dminister 30
Reassess Pt. e
nister analg
ntain airway
Continue to r

e Practition

AL PROTO
hest Pain


ure Pt.

upright positio
cannula if av

(ECG if availa
hest pain

glyceryl trini
ribed
tal signs

e after 5 mins
glyceryl trinit
tal signs

e after 5 mins
glyceryl trinit
tal signs

ved after 20 m
ceryl trinitrate
AN AMBULANC

0mgs Aspirin
every 5 mins

gesia if requ
y if necessa
reassure Pt.
ner
OCOL
on
ailable.
able)
itrate as
s
trate
s
trate
mins
e)
CE
n

uired
ary
.
If no resp
trinitrate
for furthe
managem


If Pt. expe
arrest c
support/a
as per fac

Document
current G
Emergenc

ponse to glyc
refer to cu
r advice and
ment.
eriences a c
commence b
advanced life
cility protoco
tation and r
P, transfer t
cy departme
ceryl
urrent GP
d
cardiac
basic life
e support
ol.
referral to
to nearest
ent.


Nurse Practitioner

CLINICAL PROTOCOL
Chest Pain




Goals of Treatment
Relief of symptoms
Prevention of recurrence
Prevention of complications


Drug Formulary

GLYCERYL TRINITRATE ASPIRIN
Drug (generic name): Glyceryl Trinitrate
Dosage range: 400 mgs (spray) OR 600microgram (tablet)
Route: oral (sublingual)
Frequency of administration: 5 minutely if pain persists
Duration of order: as required max of 3 metered doses, or 3
tablets (1800 micrograms).
Actions: Venodialting effects, reduction in venous return and
preload to the heart therefore reducing myocardial oxygen
requirement.
Indications for use: Prevention and treatment of angina,
acute heart failure associated with MI.
Contraindications for use: hypovolaemia, raised ICP, G6PD
deficiency (risk of haemolytic anaemia).
Adverse drug reactions: headache, flushing, palpitations,
fainting, peripheral oedema. Rarely rebound angina.
Drug (generic name): Aspirin
Dosage range: 150 - 300mg
Route: oral
Frequency of administration: immediately
Duration of order: single dose
Actions: immediate antiplatelet effect, produces complete
inhibition of thromboxane-mediated platelet aggregation
within 30 minutes.
Indications for use: Acute chest pain with suspicion of acute
coronary syndrome.
Contraindications for use: Known NSAID hypersensitivity
(esp. asthma).
Adverse drug reactions: bleeding, GI upset,



Evaluative strategies
Unexpected
representation
Review Patient Notes. Full audit of clinical
events.

NP Clinical
Practice
NP Clinical Practice/Medical Report Audit
FORMULARY


Nurse Practitioner

CLINICAL PROTOCOL
Chest Pain


Key Terms
NP Nurse Practitioner
GP General Practitioner
S4 Schedule of the drug administration
act
CP Clinical Protocol

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:
Carol Jones
Nurse Practitioner
Murray Medical Centre Mandurah





We acknowledge the authorship and
input of :











Reviewed and authorised by:
Dr. Frank Reedman Jones
MBBCh, DCH, DRCOG, FRACGP, FACRRM
Murray Medical Centre: Primary Care
Physician


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