Effective Strategies for Acute Chest Pain Management

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EMERGENCY PAIN MANAGEMENT
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Contents
INTRODUCTION.....................................................................................................................................1
BODY.....................................................................................................................................................2
RECOMMENDATIONS............................................................................................................................6
CONCLUSION.........................................................................................................................................6
REFERENCES..........................................................................................................................................8
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INTRODUCTION
The job of a nursing professional and even a health and social care worker includes
variety of situations where the life of the individual is on stake and requires a lot of
effort and knowledge to allow them recover well and have a positive patient
outcome. This assignment is a reflective piece of my own approaches and
experiences that are explained and has taught me some basic idealistic clinical
practice guidelines that are to be followed and are applicable in emergency situation.
This account will explore the variety of literature on the topic of emergency pain
management as derived from the case scenario of 43 years old women who was
treated by me and my team during my placement. The management of the acute
pain in emergency situation is essential for the nurses and health care professionals.
Acute and severe chest pain is to be managed appropriately and requires not only
physical pain management but needs to be addressed including psychological and
emotional aspects as well.
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BODY
Acute chest pain is a common problem that is encountered in the emergency
department. It is seen that in England the rapid onset acute chest pain rates are
rising and are influenced by variety of factors (Foy et al., 2015). One of my patients
while I was working in the emergency department during my placement was a 43
years old female who was admitted to the ER with complain of acute, severe and
crushing chest pain. The female has a history of migraine and recent diagnosis of
hypertension.
Before the pain is being treated or managed it is important for the nurses to
understand the extent of pain and the definition of pain for the particular patient. Pain
can be defined as unpleasant physical or emotional sensation that is related to
possible or genuine tissue damage in the body (Williams and Craig., 2016). Annual
rate of the Emergency department in the US shows around eight million hospital
admission due to chest pain (Safdar et al., 2016). The cause may vary from angina
due to coronary artery disease to micro vascular dysfunction including coronary
artery dissection, coronary artery endothelial dysfunction and myocardial bridging.
Also there may be pain due to non-cardiac causes and this has severe impact on
individual’s physical and psychological wellbeing.
It is seen that having knowledge of pain of the patient is not sufficient to manage it
(Jacob, McKenna and D'Amore., 2015). The nurse should have appropriate skills to
assess the nature of pain using a proper pain scale and then create a management
plan that will help in providing satisfactory pain management to the patient. In the
given case the female complained of severe acute chest pain (Williams and Craig.,
2016). While creating the plan for the management of her pain the team included
some professionals including the general practitioner, nurse, social worker,
physiotherapist and care assistant. In the emergency medicine mostly the role of a
multispecialty team is crucial but is not taken care in most of the settings due to the
urgent nature of the case. Here the team of professionals was gathered to assess
and implement proper management for the pain as per the diagnosis for the patient
(Jacob, McKenna and D'Amore., 2015). The team managed to first assess the pain
and using the verbal and nonverbal pain rating from the patient the nature and
intensity of the pain was assessed. As the pain was acute it was defined by the
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patient to be quick in nature and onset and shorted in duration but constant this is
similar explanation of the acute pain definition provided by Farrell and Dempsey’s
(2014). The nature of a cardiac associated acute chest pain is more over
characterized by the tight and pressurizing feeling in chest, radiating pain to jaws,
arms and back, fatigue, dizziness, breathlessness and abdominal pain and nausea
in females. The patient rated the tightness in her chest to be 8/10 on the pain scale.
Also the history of being admitted to nearby hospital with similar symptoms a month
ago was recorded. Recording appropriate history allows identifying exact mechanism
and cause of pain and in this patient the symptoms of pain were accompanied by
nausea and abdominal discomfort too with radiating pain in her back.
To understand the pain of this patient appropriately some theoretical models of pain
are to be taken into consideration. The Gate Control theory by Melzack and Wall
discusses how the pathway of pain from periphery to spinal cord is present and can
be inhibited through sensory stimulations (Chen, 2011). Such theories suggest how
the phenomenon of pain in emergency is to be perceived and how this patient was
dealing with her chest pain. Pain can be assessed verbally, by observation or by
using holistic pain assessment models. In this case we used the pain scale and
verbal explanation to assess the patient’s acute pain. As the severity and extent of
pain was beyond patient’s tolerance the management plan was quickly planned and
supported by the multidisciplinary care team efforts (Roche et al., 2017). While
assessing the pain we should observe that the pain is not only associated with the
physical symptoms but also had association and close link to depression,
psychological anguish, difficulty in coping and disturbed sleep (Stevens and Raferty.,
2018). The incapability of the individual to assess the history of pain appropriately
and to identify the factors influencing pain leads to improper diagnosis and
inappropriate emergency medicine practice.
The initial management plan supported running the electrocardiogram and
application of some emergency drugs to control the pain. According to Safder et al
(2016), the use of aspirin and analgesics is frequently done to manage the acute
chest pain in patients in emergency department. Similarly the given case was
managed by prescription of aspirin and morphine for reducing pain and management
for the patient was done. These drugs were assisted by the nurse and administered
to the patient with aim to relieve acute emergency pain (Foy et al., 2015). The
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Echocardiogram was run to specify the main cause of pain and it revealed that the
patient has a left bundle branch block (LBBB). According to Herren et al (2001), the
2 to 4% emergency hospital visit of patients mostly account for chest pain in the UK.
Nationally over 129000 deaths annually occur due to mismanaged chest pain in the
emergency department. Missed myocardial infarction diagnosis account for around
20% of the cases in the UK that is why there is special focus on the emergency
medicine and the emergency medicine needs to have proper and more improved
access and approaches to practice (Stevens and Raferty., 2018). The contact
between the patient and ED is characterized initially by the first nursing triage. Here
if the protocol is followed appropriately the care services are mentioned to be of high
quality. The role of nurse includes early ECG, clinical risk stratification, care planning
and management.
The applicable pain management techniques in this scenario should be
pharmacological and non-pharmacological interventions that are monitored and
tailored continuously. Amaya et al (2015), suggested how the opioid interventions
binds to the pain receptors and aims in reduction of the pain perception in human
body. Other than aspirin the first line drug to be administered in the case of acute
chest pain is nitroglycerine sublingually. According to Boden et al (2015), nitro-
glycerine is the oldest and most widely prescribed anti angina gent that has short
acting time and lasting effects. The author also identified that in spite of the long
history of the benefits of this medication the education of the patients and the health
care providers is lacking for its use in emergency incidence. The mechanism through
which nitro-glycerine works is by inducing vasodilation in large capacitance blood
vessels, impair platelet aggregation and increase the coronary arterial diameters and
flow (Roche et al., 2017). Hence the application of nitro-glycerine was prescribed by
the team for the current patient and it helped in achieving appropriate effects and
pain control over short duration.
Here it is suggested that use of opioids with NSAIDS or paracetamol is beneficial in
chest pain management. The role of nursing professional in pain management is to
administer medicines, monitoring of side effects ad provide patient education and
care. Timmerman et al (2014), suggested that patients with chest pain are more
likely to adhere to such pharmacological management regimes if they are provided
proper education and guidance. Pharmacological interventions can be used and is
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most applicable in the current case with beneficial and lasting effects but use of non-
pharmacological interventions is also proved to be beneficial and important in such
case. Silva et al (2014), found that TENS (Transcutaneous Electrical Neural
Stimulation therapy provides similar analgesic effects as the pharmacological
treatment and can be used to manage pain in an emergency case. Other non-
pharmacological therapies have their focus on the psychological aspect for pain
management (Hoppe et al., 2015). These psychological interventions are not proved
to be very effective in quick and emergency pain management but needs to be
delivered for better long standing effects of pain management therapy.
Other than these therapies the emergency medicine includes the implication of
surgical procedures that includes angioplasty and stent placement, bypass surgery,
dissection repair and lung reinflation as per the cause and blockage. Angioplasty in
case of cardiac blockage is commonly advised and done with good rate of prognosis
and life expectancy. In the given case the application of appropriate emergency
medicine practices were done with use of proper exploratory and diagnostic skills,
and team work with administration of drugs that helped in relieving the chest pain
and planning further care off the patient. The other further planning was done by
multiple tests and diagnostic arrays being used and with point diagnosis of the cause
and treatment for the same.
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RECOMMENDATIONS
Emergency medicine is the crucial part of health and social care and is the sector
where majority of the cases annually in every hospital setting are admitted ( Hoppe et
al., 2015). The productivity and efficacy of the emergency medicine depends of
variety of factors including the efficiency of the staff, knowledge, education and
evidence based practice being followed, the policies and legislation of the standards
of care being followed, and the patient outcomes (Kisely et al., 2015). The current
emergency practices are being followed with new strategies of care being
implemented but it is seen that overcrowding of the emergency departments
because major issues and deteriorates the efficiency of the services. According to
the article by Healthcare Analytics Summit (2019), common issues in emergency
care include patient satisfaction, health outcomes, financial, and waiting time. The
best solution for the improvement of these services involves better understanding of
the performance markers and applying strategies on its basis. Improving the triage
workflow is most important part in managing emergency chest pain patients (Stevens
and Raferty., 2018). It should aim at providing the access to the user by introducing
the triage advanced specialist practitioner for better practices. Redesigning the
discharge process and improving the response to surges in patient volume as well
as enhancing staff education on appropriate and evidence based emergency
medicine practices and enhancing the staffing patterns. These advancements and
recommendations if implemented in the emergency clinical practice it will be
beneficial to serve more patients in emergency and crises and help in better patient
outcomes.
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CONCLUSION
The management of the acute pain in emergency situation is essential for the nurses
and health care professionals. Acute and severe chest pain is to be managed
appropriately and requires not only physical pain management but needs to be
addressed including psychological and emotional aspects as well. Acute chest pain
is a common problem that is encountered in the emergency department. It is seen
that in England the rapid onset acute chest pain rates are rising and are influenced
by variety of factors. Emergency medicine or health and social care is the one where
the prompt and emergency care of the patient is implemented with appropriate
knowledge to the standards of care and ethics to practice (Than et al., 2014). The
given case of the female with acute chest pain presented in the emergency
department was well reflected upon to show how the emergency medicine and skills
are used in the delivery of care to the patient in emergency department. Use of
proper diagnostic skills and knowledge with assessment of patient needs is essential
to carry patient centered care in the emergency department.
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REFERENCES
Boden, W.E., Padala, S.K., Cabral, K.P., Buschmann, I.R. and Sidhu, M.S., 2015.
Role of short-acting nitroglycerin in the management of ischemic heart disease. Drug
design, development and therapy, 9, p.4793.
Foy, A.J., Liu, G., Davidson, W.R., Sciamanna, C. and Leslie, D.L., 2015.
Comparative effectiveness of diagnostic testing strategies in emergency department
patients with chest pain: an analysis of downstream testing, interventions, and
outcomes. JAMA internal medicine, 175(3), pp.428-436.
Health Catalyst, Healthcare Analytics Summit., 2019. Emergency Department
Quality Improvement: Transforming the Delivery of Care. Retrieved from
(https://www.healthcatalyst.com/insights/emergency-department-quality-
improvement-transforming-delivery-care) last accessed on 20/07/2019.
Herren, K.R. and Mackway-Jones, K., 2001. Emergency management of cardiac
chest pain: a review. Emergency Medicine Journal, 18(1), pp.6-10.
Hoppe, J.A., Kim, H. and Heard, K., 2015. Association of emergency department
opioid initiation with recurrent opioid use. Annals of emergency medicine, 65(5),
pp.493-499.
Jacob, E.R., McKenna, L. and D'Amore, A., 2015. The changing skill mix in nursing:
considerations for and against different levels of nurse. Journal of Nursing
Management, 23(4), pp.421-426.
Kisely, S.R., Campbell, L.A., Yelland, M.J. and Paydar, A., 2015. Psychological
interventions for symptomatic management of non‐specific chest pain in patients with
normal coronary anatomy. Cochrane Database of Systematic Reviews, (6).
Roche, T.E., Gardner, G. and Jack, L., 2017. The effectiveness of emergency nurse
practitioner service in the management of patients presenting to rural hospitals with
chest pain: a multisite prospective longitudinal nested cohort study. BMC health
services research, 17(1), p.445.
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Safdar, B. and D’Onofrio, G., 2016. Focus: Sex and Gender Health: Women and
Chest Pain: Recognizing the Different Faces of Angina in the Emergency
Department. The Yale journal of biology and medicine, 89(2), p.227.
Stevens, A. and Raferty, J., 2018. Health Care Needs Assessment: The
Epidemiologically Based Needs Assessment Review. CRC Press.
Than, M., Aldous, S., Lord, S.J., Goodacre, S., Frampton, C.M., Troughton, R.,
George, P., Florkowski, C.M., Ardagh, M., Smyth, D. and Jardine, D.L., 2014. A 2-
hour diagnostic protocol for possible cardiac chest pain in the emergency
department: a randomized clinical trial. JAMA internal medicine, 174(1), pp.51-58.
Williams, A.C.D.C. and Craig, K.D., 2016. Updating the definition of
pain. Pain, 157(11), pp.2420-2423.
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