Effective pain relief is a priority. Monitoring and documenting characteristics of pain and pain score including nonverbal cues, BP and HR changes are important. Nurses should make sure Mr. Peter’s systolic blood pressure (BP) is over 100 before administering glycerly trinitrate (GTN) sublingually, since it reduces oxygen demand and increases oxygen delivery (Berman, Kozier & Erb 2015). 6 rights (mediation, time, route, patient, dosage and documentation) need to be confirmed. The regime of GTN is 1 tablet per every 5 minutes up to 3 times, and BP and RR should be taken in between (Bryant & Knights 2015). After giving GTN, nurses assess Mr. Peter’s pain and compare pain score with the one before. If Mr. Peters still has pain after 3 GTN administration, morphine can be administered intravenously (Berman,
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Peters cardiac condition and document it along with Possible Cardiac Chest Pain Clinical Pathway form. Since Mr. Peter has arrhythmia, a 12-lead ECG needs to be measured periodically, and nurses need to monitor any other changes such as ST segment depression or elevation, or T-wave inversion (Farrell et al. 2016). Vital signs need to be continually monitored and documented hourly at a minimum. Oxygen saturation measurement is required at all times using pulse oximetry. Unless arterial oxygen saturation level is less than 90% supplemental oxygen therapy is not required (Franczyk-Skóra et al. 2013). HR, BP and RR also need to be continually monitored. Since Mr. Peters has arrhythmia, HR needs to be checked by palpation of the pulse. RR should be cross checked with ECG and the patient’s counted rate (Barthel et al. 2012). Continuous circulation assessment is also required.
Tn is not detectable early after onset of chest pain, therefore, serial measurements of Tn is required over a period of time (Franczyk-Skóra et al. 2013). If Tn rises, coronary angiography may be performed (Farrell et al.
Peters cardiac condition and document it along with Possible Cardiac Chest Pain Clinical Pathway form. Since Mr. Peter has arrhythmia, a 12-lead ECG needs to be measured periodically, and nurses need to monitor any other changes such as ST segment depression or elevation, or T-wave inversion (Farrell et al. 2016). Vital signs need to be continually monitored and documented hourly at a minimum. Oxygen saturation measurement is required at all times using pulse oximetry. Unless arterial oxygen saturation level is less than 90% supplemental oxygen therapy is not required (Franczyk-Skóra et al. 2013). HR, BP and RR also need to be continually monitored. Since Mr. Peters has arrhythmia, HR needs to be checked by palpation of the pulse. RR should be cross checked with ECG and the patient’s counted rate (Barthel et al. 2012). Continuous circulation assessment is also required.
Tn is not detectable early after onset of chest pain, therefore, serial measurements of Tn is required over a period of time (Franczyk-Skóra et al. 2013). If Tn rises, coronary angiography may be performed (Farrell et al.