Post operative chest pain

Post Operative Chest Pain: Eliciting the underlying cause Raymond Zakhari, NP www.MetroMedicalDirect.com

Most Common Etiologies
Cardiac
Pulmonary
Gastric
Musculo-skeletal

History: Key questions to ask
Where is the pain or pressure located?
Point with one finger
Use the same words back to the patient when assessing, reassessing, and documenting
It is very important to clearly elicit what the patient means by the word pain
Sharp
Dull
Aching
Burning

Detailed history: Quality
Quantify the pain or pressure
1-10 scale?
What is it at it’s worst?
What is it at it’s best?
Is it tolerable?
Repeat this after each intervention
Have you ever had this pain or pressure before?
Tell me about that time
What was done about it?
Is there anything different about this incident from the last time?

Detailed History: Character
Is the pain constant or intermittent?
How long between episodes of pain?
How long does each episode last?
Is each episode getting progressively better or worse?
How long have you been experiencing this episode of pain?
Are there any other associated symptoms with this?
Nausea
Vomiting
Dizziness
Numbness/ tingling
Sweating
Itching
Sense of impending doom
Anxiety
Bad or sour taste in your mouth
Does the pain radiate?
Jaw
Neck
Teeth
Shoulder
Nose
Eyes

Detailed History: Aggravating & Alleviating Factors
Does anything make the pain better or worse?
Movement
Reaching
Walking
Position changes
Touching the site of pain
Breathing

Physical Exam: Vital Signs
Apical Heart Rate compared to Radial Pulse for 1 minute
Check peripheral pulses compare to baseline quality
Respiratory Rate including depth and pattern
Blood pressure compared to baseline
Oxygen Saturation (hand should be covered, and heart rate should correlate)
Oral Temperature
Finger Stick Blood glucose

Physical Exam: Neuro & Psych
Is the person Awake, Alert & oriented to person, time, place and purpose?
Are they speaking in normal voice?
Rate of speech?
Organized thought progression?
Appropriate answers to simple questions?
Able to follow commands?

Physical Exam: Cardiac & Pulmonary
Lung Sounds and Effort
Clear and unlabored vs. crackles with accessory muscle use?
Does the patient assume a certain posture to help with breathing?
How many balls can they raise on the incentive spirometer compared to previous?
Are the neck veins distended?
Are all pulses symmetrical and palpable

Physical Exam: Abdomen/ Extremities
Is there Abdominal Distension?
Hyperactive bowel sounds
Is there any swelling, heat or discoloration of an extremity?
Is this bilateral or unilateral?
Is it a change from baseline?
Is there an obvious external cause?
Immobility
Tourniquet, ID bracelet, BP cuff, compression device, ice pack, heat pack

Clinical Characteristics: Cardiac etiology
Pain is often called pressure
+/- Radiating (Vagus Nerve Innervation post cardiac transplant patients usually do not radiate )
+/- nausea or vomiting
+/- Lightheadedness
+/- Numbness/ tingling
+/- Sweating
Last longer than 5 minutes
Episodes should be triggered by exertion
Constant while at rest
Not made better or worse by palpation or reaching

Clinical Characteristics: Pulmonary Embolus
Chest pain worse with deep breathing
Low or downward trending SpO2
Tachycardia or heart rate trending upward (minus other causes)
Patient becoming restless or agitated
Risk factors present (history of clots, long travel, normally on anticoagulant)

Clinical Characteristics: Gastric related chest pain/ pressure
Pain is changed (usually improved) by positioning, palpation, movement
Abdominal distension
Associated bloating
Eructating and passing flatus
Acidic taste or sour taste in mouth
Associated heart burn or history of reflux

Clinical characteristics: Musculoskeletal Chest Pain
Pain is made worse with movement
Pressing on a certain point makes pain worse
Patient is guarded in their movement
Topical agents relieve the pain (heat rub, ice pack etc.)
No other associated symptoms and or history of recent/ remote trauma

When in doubt:
Take a History and Physical
Check a complete set of Vital Signs
HR, BP, RR, T, SpO2, Finger stick (low blood sugar can cause anxiety and somatization and altered mental status)
Do a 12 Lead ECG
Page the NP, Primary Team
If no response or decompensating call Rapid Response (44444)

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Post operative chest pain

by Raymond Zakhari on Apr 22, 2010

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Post operative chest pain — Presentation Transcript