Patient is complaining of CP

Question

He has a history of GERD and is on prn medication for indigestion and reflux. What is your next step in caring for this patient?

Answer 1

If offered the choice of a "priority nursing intervention" or "place the nursing interventions in order of their priority" on NCLEX for the patient with chest pain regardless of GERD history by using the Nursing Process and ABCs...

First, Assessment (first step of the Nursing Process): 

Obtain vital signs and a 12-lead EKG.

1. Remember, we are on NCLEX island. We have all these fantastic resources, perfect staff, and a provider with us to diagnose the patient immediately (unless otherwise stated in the question stem). 12-lead EKG is needed to rule out an S-T elevated MI (STEMI); labs would be the next choice with this as they would rule out a non-S-T elevated MI (non-STEMI) by the provider.

Symptom questions while assessing. 

1. Last meal? Take any Aspirin? If so, how much? Cardiac history? Take their PRN anti-reflux medication? Most importantly, when suspecting MI - what were they doing when the pain started, and did it get better when they stopped doing what they were doing or was it unchanged? (Example - they were walking when it started, stopped, and the pain continued/did not "get better".)

Second, Interventions (the third step of the Nursing Process) and follow the "ABCs" (airway, breathing, circulation)

Sit the patient up as a priority intervention due to a decrease in GERD-like symptoms, decrease the heart's workload (gravity is our friend at times), and ease the work of breathing.

1. Chest pain can be somewhat relieved when sitting up if it is related to GERD alone and not a myocardial infarction (MI). 

Supplemental oxygen at 2 LPM via NC will not hurt. This will also help decrease the heart's workload and positively impact perfusion (delivery of oxygen and nutrients) if an MI is suspected. 

1. Nursing interventions are utilized to treat an MI before we move on to the medical ones unless otherwise indicated in the question's stem.

Obtain Intravenous (IV) access. This would be the "C" if offered on the NCLEX.

Fourth, medical interventions, since we exhausted what was in our scope of practice, we can move onto ordered medications: Aspirin, Nitroglycerin, and Morphine.

1. Aspirin at 325 mg orally (do not give if aortic dissection is suspected) - assists in decreasing platelet aggregation and prevents clots from forming.
2. Nitroglycerin 0.4 mg sublingual x 3, 5 minutes apart (do not give if the patient is hypotensive; suspected inferior MI -right-sided heart failure; we need that left ventricle to work well now to compensate) - lowers left ventricular filling pressure (preload) and systemic vascular resistance (afterload when the left ventricular pushes out the blood) as it is a vasodilator. 
3. Morphine, as ordered (do not give if the patient is hypotensive; suspected inferior MI will cause bradycardia as well), provides pain relief/comfort by decreasing anxiety/pain and causing increased muscle relaxation (sympathetic nervous system) to reduce the heart's workload.

Fifth, evaluation (the fifth step of the Nursing Process): Continue to monitor the patient, especially vital signs (blood pressure and heart rate), for improved or further alterations in perfusion (increasing BP, bradycardia/tacpatient's tachypnea).

1. Vital signs (vitalS are vital!), patient's mentation, and “look" are our direct, easy assessments of their perfusion. In a suspected MI, perfusion is everything to save what we can of the heart to impact quality of life.
2. We keep assessing, then planning and interving, and evaluting. It is a continious loop.

Answer 2

Assess the pain to determine the location, duration, severity, type of pain and if there are any other symptoms in association with the pain, such as SOB, sweating, chest pressure, radiating shoulder / arm/ jaw pain. Are there changes in VS. Is the patient nauseated, vomiting, dizzy or anxious? Differentiate between reflux and cardiac symptoms so an accurate nursing diagnosis can be made. Always rule out more serious implications of chest pain before assuming the patient is suffering from GERD. PRN medication for reflux will not harm the patient if given, but be sure to rule out a cardiac event in all instances of chest pain.