Post operative chest pain


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Post operative chest pain

  1. 1. Post Operative Chest Pain: Eliciting the underlying cause Raymond Zakhari, NP
  2. 2. Most Common Etiologies <ul><li>Cardiac </li></ul><ul><li>Pulmonary </li></ul><ul><li>Gastric </li></ul><ul><li>Musculo-skeletal </li></ul>
  3. 3. History: Key questions to ask <ul><li>Where is the pain or pressure located? </li></ul><ul><ul><li>Point with one finger </li></ul></ul><ul><ul><li>Use the same words back to the patient when assessing, reassessing, and documenting </li></ul></ul><ul><li>It is very important to clearly elicit what the patient means by the word pain </li></ul><ul><ul><li>Sharp </li></ul></ul><ul><ul><li>Dull </li></ul></ul><ul><ul><li>Aching </li></ul></ul><ul><ul><li>Burning </li></ul></ul>
  4. 4. Detailed history: Quality <ul><li>Quantify the pain or pressure </li></ul><ul><ul><li>1-10 scale? </li></ul></ul><ul><ul><li>What is it at it’s worst? </li></ul></ul><ul><ul><li>What is it at it’s best? </li></ul></ul><ul><ul><li>Is it tolerable? </li></ul></ul><ul><li>Repeat this after each intervention </li></ul><ul><li>Have you ever had this pain or pressure before? </li></ul><ul><ul><li>Tell me about that time </li></ul></ul><ul><ul><li>What was done about it? </li></ul></ul><ul><ul><li>Is there anything different about this incident from the last time? </li></ul></ul>
  5. 5. Detailed History: Character <ul><li>Is the pain constant or intermittent? </li></ul><ul><ul><li>How long between episodes of pain? </li></ul></ul><ul><ul><li>How long does each episode last? </li></ul></ul><ul><ul><li>Is each episode getting progressively better or worse? </li></ul></ul><ul><li>How long have you been experiencing this episode of pain? </li></ul><ul><li>Are there any other associated symptoms with this? </li></ul><ul><ul><li>Nausea </li></ul></ul><ul><ul><li>Vomiting </li></ul></ul><ul><ul><li>Dizziness </li></ul></ul><ul><ul><li>Numbness/ tingling </li></ul></ul><ul><ul><li>Sweating </li></ul></ul><ul><ul><li>Itching </li></ul></ul><ul><ul><li>Sense of impending doom </li></ul></ul><ul><ul><li>Anxiety </li></ul></ul><ul><ul><li>Bad or sour taste in your mouth </li></ul></ul><ul><ul><li>Does the pain radiate? </li></ul></ul><ul><ul><ul><li>Jaw </li></ul></ul></ul><ul><ul><ul><li>Neck </li></ul></ul></ul><ul><ul><ul><li>Teeth </li></ul></ul></ul><ul><ul><ul><li>Shoulder </li></ul></ul></ul><ul><ul><ul><li>Nose </li></ul></ul></ul><ul><ul><ul><li>Eyes </li></ul></ul></ul>
  6. 6. Detailed History: Aggravating & Alleviating Factors <ul><li>Does anything make the pain better or worse? </li></ul><ul><ul><li>Movement </li></ul></ul><ul><ul><ul><li>Reaching </li></ul></ul></ul><ul><ul><ul><li>Walking </li></ul></ul></ul><ul><ul><ul><li>Position changes </li></ul></ul></ul><ul><ul><li>Touching the site of pain </li></ul></ul><ul><ul><li>Breathing </li></ul></ul>
  7. 7. Physical Exam: Vital Signs <ul><ul><li>Apical Heart Rate compared to Radial Pulse for 1 minute </li></ul></ul><ul><ul><ul><li>Check peripheral pulses compare to baseline quality </li></ul></ul></ul><ul><ul><li>Respiratory Rate including depth and pattern </li></ul></ul><ul><ul><li>Blood pressure compared to baseline </li></ul></ul><ul><ul><li>Oxygen Saturation (hand should be covered, and heart rate should correlate) </li></ul></ul><ul><ul><li>Oral Temperature </li></ul></ul><ul><ul><li>Finger Stick Blood glucose </li></ul></ul>
  8. 8. Physical Exam: Neuro & Psych <ul><li>Is the person Awake, Alert & oriented to person, time, place and purpose? </li></ul><ul><li>Are they speaking in normal voice? </li></ul><ul><ul><li>Rate of speech? </li></ul></ul><ul><ul><li>Organized thought progression? </li></ul></ul><ul><ul><li>Appropriate answers to simple questions? </li></ul></ul><ul><ul><li>Able to follow commands? </li></ul></ul>
  9. 9. Physical Exam: Cardiac & Pulmonary <ul><li>Lung Sounds and Effort </li></ul><ul><ul><li>Clear and unlabored vs. crackles with accessory muscle use? </li></ul></ul><ul><ul><li>Does the patient assume a certain posture to help with breathing? </li></ul></ul><ul><ul><li>How many balls can they raise on the incentive spirometer compared to previous? </li></ul></ul><ul><li>Are the neck veins distended? </li></ul><ul><ul><li>Are all pulses symmetrical and palpable </li></ul></ul>
  10. 10. Physical Exam: Abdomen/ Extremities <ul><li>Is there Abdominal Distension? </li></ul><ul><ul><li>Hyperactive bowel sounds </li></ul></ul><ul><li>Is there any swelling, heat or discoloration of an extremity? </li></ul><ul><ul><li>Is this bilateral or unilateral? </li></ul></ul><ul><ul><li>Is it a change from baseline? </li></ul></ul><ul><ul><li>Is there an obvious external cause? </li></ul></ul><ul><ul><ul><li>Immobility </li></ul></ul></ul><ul><ul><ul><li>Tourniquet, ID bracelet, BP cuff, compression device, ice pack, heat pack </li></ul></ul></ul>
  11. 11. Clinical Characteristics: Cardiac etiology <ul><li>Pain is often called pressure </li></ul><ul><li>+/- Radiating (Vagus Nerve Innervation post cardiac transplant patients usually do not radiate ) </li></ul><ul><li>+/- nausea or vomiting </li></ul><ul><li>+/- Lightheadedness </li></ul><ul><li>+/- Numbness/ tingling </li></ul><ul><li>+/- Sweating </li></ul><ul><li>Last longer than 5 minutes </li></ul><ul><li>Episodes should be triggered by exertion </li></ul><ul><li>Constant while at rest </li></ul><ul><li>Not made better or worse by palpation or reaching </li></ul>
  12. 12. Clinical Characteristics: Pulmonary Embolus <ul><li>Chest pain worse with deep breathing </li></ul><ul><li>Low or downward trending SpO2 </li></ul><ul><li>Tachycardia or heart rate trending upward (minus other causes) </li></ul><ul><li>Patient becoming restless or agitated </li></ul><ul><li>Risk factors present (history of clots, long travel, normally on anticoagulant) </li></ul>
  13. 13. Clinical Characteristics: Gastric related chest pain/ pressure <ul><li>Pain is changed (usually improved) by positioning, palpation, movement </li></ul><ul><li>Abdominal distension </li></ul><ul><li>Associated bloating </li></ul><ul><li>Eructating and passing flatus </li></ul><ul><li>Acidic taste or sour taste in mouth </li></ul><ul><li>Associated heart burn or history of reflux </li></ul>
  14. 14. Clinical characteristics: Musculoskeletal Chest Pain <ul><li>Pain is made worse with movement </li></ul><ul><li>Pressing on a certain point makes pain worse </li></ul><ul><li>Patient is guarded in their movement </li></ul><ul><li>Topical agents relieve the pain (heat rub, ice pack etc.) </li></ul><ul><li>No other associated symptoms and or history of recent/ remote trauma </li></ul>
  15. 15. When in doubt: <ul><li>Take a History and Physical </li></ul><ul><li>Check a complete set of Vital Signs </li></ul><ul><ul><li>HR, BP, RR, T, SpO2, Finger stick (low blood sugar can cause anxiety and somatization and altered mental status) </li></ul></ul><ul><li>Do a 12 Lead ECG </li></ul><ul><li>Page the NP, Primary Team </li></ul><ul><li>If no response or decompensating call Rapid Response (44444) </li></ul>