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12757681
Chest Pain
Descripción
Acute Mapa Mental sobre Chest Pain, creado por TAFE Southbank Nursing el 12/03/2018.
Sin etiquetas
acute
Mapa Mental por
TAFE Southbank Nursing
, actualizado hace más de 1 año
Más
Menos
Creado por
TAFE Southbank Nursing
hace casi 7 años
17
0
0
Resumen del Recurso
Chest Pain
GTN Protocol
first dose RN must administer
Redo
pain assessment
ECG
Observations
Check 6 rights 3 checks
SL route
dont swallow
Dont chew
allow it to dissolve under the tongue
Explain why, medication wont work effectively
Spray or tablet
every 5 minutes
max dose
1800mcg
No resolution call MET
max 3 doses
WH if systolic less than 100
Discuss side effects
nausea
dizzy
light headed
Drop in BP
falls risk
bed pan/ bottle
ensure buzzer is close
Positioning
sit the patient up
ECG
Document if during pain or post
? hairy, clammy, large breasted
remove the bra
shave hair
V1 & V2 4th intercostal space either side of sternum
V4 mid clavicular line bellow nipple
V6 mid axillary line
V3 betweel V4 and V2
V5 between V4 and V6
Ensure patient breaths normally
Ensure patient remains still
Ensure patient doesn't cross their legs
Ensure patient privacy
pain assessment PQRSTU
Provoke
what makes it worse what makes it better
Quality
Describe the pain, sharp, dull, chrushing
Radiation
Does the pain move, throat, neck, arm
Severity
How would you score the pain 0-10
Timing
When did it start, how long for
Understanding
Have you had this before what did you do last time
Get help
Call MO
ISBAR
obs
medication
Call RN
assistance with patient
bring GTN
Bring ECG
Call Supervisor
delegate patient load
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