Chest pain or angina is the discomfort a person experiences when the heart does not get enough oxygen. Chest pain is not a disease itself, but a symptom of an underlying cause.
The pain felt in angina can be described as squeezing, dull, sharp, crushing, or burning. Severe chest pain may be described as extreme pressure, such as someone or something sitting on the chest. The pain may radiate to the neck, jaw, or extremities.
In this article:
- Types
- Risk Factors
- Nursing Process
- Nursing Care Plans
- Anxiety
- Decreased Cardiac Output
- Risk for Decreased Cardiac Tissue Perfusion
- Risk for Unstable Blood Pressure
Types
Chest pain is essentially a symptom of an underlying problem like coronary artery disease (CAD), coronary microvascular disease (MVD), pleuritis, pulmonary embolism, pneumothorax, and gastroesophageal reflux disease (GERD).
There are different types of angina:
- Stable Angina. This type of angina is also referred to as angina pectoris and occurs due to CAD with decreased oxygenated blood flow to the heart muscles due to narrowed or blocked arteries. This type of chest pain is often predictable and resolves with rest or medication.
- Unstable Angina. This type of angina causes unexpected and sudden chest pain usually occurring while at rest due to a rupture of unstable plaque. Immediate diagnosis and treatment are required.
- Variant (Prinzmetal) Angina. Variant angina is characterized by pain caused by coronary vasospasm usually happening between midnight and early morning while the patient is at rest.
Risk Factors
The major risk factors of angina include the following:
- High cholesterol
- Hypertension
- Smoking
- Overweight or obesity
- Diabetes
- Metabolic syndrome
- Sedentary lifestyle
- Unhealthy diet
- Family history of heart disease
- Old age (men above 45 years old and women above 55 years old)
Prompt diagnosis and treatment of chest pain are important to prevent myocardial infarction. Physical assessment and risk identification are essential. Diagnostic exams like an electrocardiogram, blood tests, stress tests, coronary angiography, chest x-ray, cardiac catheterization, or computed tomography angiography (CTA) can confirm and treat the underlying condition that is causing the chest pain.
Nursing Process
Nurses play a vital role in conducting a comprehensive pain assessment as this can promote prompt diagnosis and treatment of chest pain.
The goal of treatment for patients with chest pain include:
- Accurate identification of the type of angina and its underlying cause
- Immediate and appropriate treatment
- Medications for pain relief and vasodilation
- Preservation of heart muscles if myocardial infarction is suspected
- Lifestyle modifications to reduce risks
Patient education is a priority and includes how to recognize symptoms of stable vs. other types of chest pain, treatment, and when to seek emergency assistance.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for chest pain, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section you will find nursing care plan examples for chest pain.
Acute Pain
Chest pain may be described as squeezing, tight, sharp, or dull. It may be confused with indigestion as it can be a burning sensation. Patients may describe pressure akin to “an elephant sitting on my chest.”
Nursing Diagnosis: Acute Pain
Related to:
- Myocardial injury
- Ischemia
- Disease process
- Physical exertion
As evidenced by:
- Diaphoresis
- Distraction behavior
- Expressions of chest pain/pressure/tightness/etc.
- Facial expression of pain
- Guarding behavior
- Positioning to ease pain
- Clutching of chest
- Tachycardia
Expected outcomes:
- Patient will demonstrate the resolution of chest pain.
- Patient will identify potential causes of chest pain.
Assessment:
1. Assess pain characteristics noting location and type of pain.
It is important to distinguish when the chest pain started, precipitating factors, pain characteristics, duration, and location for appropriate diagnosis and management.
2. Assess diagnostic test results.
A 12-lead ECG is often obtained immediately for patients with chest pain to confirm or rule out myocardial infarction.
3. Assess for a history of chest pain.
Assessing if the patient has a history of chest pain and if this pain feels similar to other episodes can help the nurse in directing treatment.
Interventions:
1. Administer pain medications as indicated.
Drug therapy for chest pain aims to promote pain relief and reduce the risks of myocardial infarction and death. Medications like short-acting nitrates, angiotensin-converting enzyme inhibitors, analgesics, and calcium channel blockers are given to promote myocardial perfusion.
2. Provide oxygen supplementation if necessary.
Supplemental oxygen is provided to increase oxygenation to the myocardium. If oxygenation levels are normal, this may not be necessary.
3. Prepare for further testing.
Stress tests, echocardiograms, and CTAs assess the need for further treatment. These tests can visualize blockages within coronary arteries.
4. Provide patient education.
Ensure the patient understands how to recognize and treat stable angina. Offer education on administering nitroglycerin tablets and when to seek further assistance.
Anxiety
The feeling of chest pain and its related symptoms can cause fear and anxiety.
Nursing Diagnosis: Anxiety
Related to:
- The potential threat of death
- Unfamiliar situation
- Threat to change in health status
As evidenced by:
- Expresses alarm
- Expresses fear
- Expresses panic
- Nausea
- Dry mouth
- Palpitations
- Inability to focus
- Tachycardia
- Tachypnea
- Diaphoresis
Expected outcomes:
- Patient will verbalize strategies to cope with fear and anxiety related to chest pain.
- Patient will verbalize a sense of safety and feelings of decreased fear.
Assessment:
1. Assess the patient’s feelings of fear/anxiety.
Discuss with the patient the exact thoughts and feelings they are having. The nurse can help alleviate unnecessary fear after the patient expresses their concerns.
Interventions:
1. Provide verbal and physical reassurance of safety.
Providing support and reassurance while the patient verbalizes fear and emotions can help reduce the patient’s anxiety levels. The nurse may also calmly rub the patient’s back or hold their hand to offer physical support.
2. Explore positive coping mechanisms with the patient.
Chest pain, dyspnea, and other symptoms can be alarming. Teach the patient strategies to calm themselves such as breathing exercises or distraction.
3. Administer anti-anxiety medications.
Fear and anxiety can be disruptive to the body and worsen outcomes. Administer benzodiazepines if necessary to promote relaxation and reduce fear.
4. Arm with knowledge.
A patient who is confident in monitoring and managing their health will experience less fear and anxiety. Discuss the patient’s chest pain, symptoms, and treatment once the threat has resolved so they feel in control.
Decreased Cardiac Output
Decreased cardiac output can be caused by insufficient blood flow to the heart leading to chest pain and a poor supply of oxygenated blood (cardiac output) throughout the body.
Nursing Diagnosis: Decreased Cardiac Output
Related to:
- Ineffective cardiac muscle contraction
- Conditions that compromise the blood supply
- Narrowed arteries
- Blocked arteries
- Rupture of unstable plaque
- Coronary vasospasm
- Malfunctions of the heart structures
- Difficulty of the heart muscle to pump
As evidenced by:
- Increased central venous pressure (CVP)
- Tachycardia
- Dysrhythmias
- Ejection fraction less than 40%
- Decreased oxygen saturation
- Presence of abnormal heart sound S4 upon auscultation
- Chest pain (angina)
- Increased blood pressure (hypertension)
- Difficulty breathing (dyspnea)
- Rapid breathing (tachypnea)
- Alteration in the level of consciousness
- Restlessness
- Fatigue
- Inadequate tolerance in activities
- Cold and clammy skin
- Prolonged capillary refill time
- Edema
Expected outcomes:
- Patient will manifest adequate cardiac output as evidenced by normal sinus rhythm on ECG.
- Patient will demonstrate hemodynamic stability by vital signs (particularly the heart rate) within the normal range.
- Patient will not experience dyspnea, restlessness, or fatigue from reduced cardiac output.
Assessment:
1. Assess the signs and symptoms along with chest pain.
The following signs and symptoms can occur with chest pain and may signal a decrease in cardiac output and perfusion to different organs:
- Excessive sweating (diaphoresis)
- Dyspnea
- Cough
- Nausea and vomiting
- Abdominal pain
- Fever
- Edema
- Calf pain
- Swelling of the lower extremities
2. Monitor the heart rate.
Most anginal episodes begin with an increase in heart rate as the heart attempts to compensate.
3. Obtain ECG.
Exercise or medication stress testing, nuclear perfusion imaging, and diagnostic cardiac catheterization are all useful tests. ECG alterations such as ST elevation, atrial fibrillation, or tachycardic rhythms drive further treatment.
4. Review lab results.
A complete blood count (CBC) identifies disorders like leukemia, anemia, and infections. It also measures the red blood cells that deliver oxygen. A basic metabolic panel (BMP) measures electrolyte levels as well as kidney function. Both tests indicate the sufficiency of oxygenated blood from the heart to different organs.
Interventions:
1. Treat the underlying cause.
Non-cardiac factors, non-ischemic cardiac disease, and ischemic cardiac disease can produce chest pain, resulting in an imbalance between the heart’s oxygen supply and demand.
- Non-cardiac causes include lung disease, musculoskeletal issues, anxiety/panic attacks, and gastric reflux disease.
- Pericardial disease is a possible non-ischemic cardiac cause.
- Coronary artery atherosclerosis and myocardial infarction are common causes of cardiac ischemia.
2. Risk factor management.
Blood pressure, cholesterol, and blood sugar are controllable risk factors. Educate patients on medications and lifestyle modifications to reduce their individual risks.
3. Encourage participation and adherence to lifestyle modification.
Lifestyle modifications reduce further plaque buildup and lessen blood vessel damage to maintain patent blood flow and supply. Regular exercise, maintaining a healthy weight, and quitting smoking are lifestyle changes that should be included in the patient’s education.
4. Administer medications as ordered.
Antianginal medications such as nitroglycerin provide immediate relief of angina. The general goal of symptomatic control is to reduce myocardial oxygen demand.
5. Control the heart rate.
Three angina medications—beta-blockers, ivabradine, and non-dihydropyridine calcium channel blockers—reduce symptoms by lowering the heart rate. Calcium channel blockers should not be given in patients with a low ejection fraction and left ventricular failure.
Risk for Decreased Cardiac Tissue Perfusion
Chest pain may indicate cardiac conditions like myocardial infarction, heart failure, and CAD, increasing the risk for decreased cardiac tissue perfusion.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Heart disease/atherosclerosis
- Hypoxia
- Myocardial infarction
- Ischemia
- Hypoxemia
As evidenced by:
A risk diagnosis is not evidenced by any signs and symptoms, as the problem has not occurred yet and the nursing interventions will be directed at the prevention of symptoms.
Expected outcomes:
- Patient will not experience a myocardial infarction.
- Patient will report and display improvement in dyspnea, oxygen saturation, and vital signs.
Assessment:
1. Assess symptoms and risk for impaired cardiac tissue perfusion.
Chest pain, shortness of breath, diaphoresis, indigestion, and associated anxiety can indicate decreased cardiac perfusion.
2. Obtain lab work.
Cardiac enzymes such as troponin levels, electrolytes, ABGs, and more are important to obtain when analyzing chest pain.
3. Monitor telemetry.
Blood pressure, pulse, ECG, and O2 saturation should be monitored continuously for changes.
Interventions:
1. Reduce cardiac workload.
Supplemental oxygen promotes oxygenation. Encourage bed rest or limit activity to prevent oxygen consumption and reduce cardiac workload.
2. Prepare for surgical interventions.
Cardiac catheterization can be used to visualize narrowed or blocked arteries and allow for stent placement. CABG may be required to reroute blood to the heart.
3. Administer medications as ordered.
Vasodilators relax and open blood vessels. Anticoagulants keep blood thin. Digoxin increases cardiac output. Antihypertensives reduce the force on arteries.
4. Educate the patient on lifestyle modifications.
Treating the underlying cause requires lifestyle modifications such as reducing sodium and fat intake, quitting smoking, and increasing physical activity.
Risk for Unstable Blood Pressure
Depending on the underlying cause of chest pain, hypotension or hypertension may occur.
Nursing Diagnosis: Risk for Unstable Blood Pressure
Related to:
- Ineffective cardiac muscle contraction
- Conditions that compromise the blood supply
- Narrowed arteries
- Blocked arteries
- Rupture of unstable plaque
- Coronary vasospasm
- Malfunctions of the heart structures
- Increased cardiac workload
- Dysrhythmias
- Electrolyte imbalances
- Fluid retention
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Patient will maintain blood pressure within acceptable limits.
- Patient will remain free from orthostatic changes, such as dizziness when standing.
- Patient will verbalize when to contact their provider due to hyper or hypotension.
Assessment:
1. Measure the patient’s blood pressure routinely.
In unstable angina, increased oxygen demand occurs at rest, while in stable angina, it occurs during exertion. Exercise-induced demand increases in heart rate, blood pressure, and myocardial contractility are the leading causes of increased myocardial oxygen demand.
2. Assess subjective symptoms.
Inquire if the patient ever feels their heart “skip beats” or if they experience headaches, lightheadedness, or dizziness. The patient may be experiencing symptoms of hyper or hypotension.
3. Review the patient’s medications.
Polypharmacy increases the risk of hyper and hypotension, especially in older adults. Multiple antihypertensive medications, diuretics, antidepressants, and herbal remedies can affect blood pressure.
Interventions:
1. Prevent excess exertion.
Angina can produce pressure, squeezing, soreness, or a sense of fullness in the chest when patients with high blood pressure engage in strenuous exercise, walking uphill, or climbing stairs.
2. Educate on when to seek help for uncontrolled blood pressure.
The patient may not know what constitutes “too high” or “too low.” Encourage them to monitor their blood pressure regularly as ordered, and especially when symptoms occur. Advise on blood pressure findings that require immediate attention.
3. Encourage commitment to lifestyle change.
Simple lifestyle adjustments can lower high blood pressure by 10–20 mmHg or more. This includes eating less sodium, exercising frequently, keeping a healthy weight, consuming less alcohol, and quitting smoking.
4. Strategize to increase blood pressure control.
Nurses are essential in monitoring, evaluating, and encouraging patients’ participation in blood pressure control. The following are strategies for increasing adherence:
- Giving clear, concise, and logical instructions in understandable language
- Adjusting treatment regimens to once daily schedules
- Encouraging patient participation through self-monitoring
- Providing learning materials promoting overall good health
References
- American Heart Association. (2017, December 14). Angina (Chest pain). www.heart.org. Retrieved February 2023, from https://www.heart.org/en/health-topics/heart-attack/angina-chest-pain
- Chest Pain. Cleveland Clinic. May 23, 2022. https://my.clevelandclinic.org/health/symptoms/21209-chest-pain
- Chest Pain. Mayo Clinic. October 20, 2021. https://www.mayoclinic.org/diseases-conditions/chest-pain/symptoms-causes/syc-20370838
- Cleveland Clinic. (2022, May 23). Chest pain: Causes and what it feels like. Retrieved February 2023, from https://my.clevelandclinic.org/health/symptoms/21209-chest-pain
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
- Goyal A, Zeltser R, Gunn AA. Unstable Angina (Nursing) [Updated 2022 May 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK568785/
- Mayo Clinic. (2021, October 20). Chest pain – Symptoms and causes. Retrieved February 2023, from https://www.mayoclinic.org/diseases-conditions/chest-pain/symptoms-causes/syc-20370838
- Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.
- Mount Sinai Health System. (n.d.). Chest pain. Retrieved February 2023, from https://www.mountsinai.org/health-library/symptoms/chest-pain
- National Center for Biotechnology Information. (2022, July 12). Chest pain – StatPearls – NCBI bookshelf. Retrieved February 2023, from https://www.ncbi.nlm.nih.gov/books/NBK470557/
- Stuart, A. (2010, March 17). Chest pain causes. WebMD. Retrieved February 2023, from https://www.webmd.com/pain-management/guide/whats-causing-my-chest-pain
- What’s Causing My Chest Pain? WebMD. 2021. https://www.webmd.com/pain-management/guide/whats-causing-my-chest-pain
