Chest pain
Chest pain: Excerpt from Nursing: Interpreting Signs and Symptoms
Chest pain usually results from disorders that affect thoracic or abdominal organs—the heart, pleurae, lungs, esophagus, rib cage, gallbladder, pancreas, or stomach. An important indicator of several acute and life-threatening cardiopulmonary and GI disorders, chest pain can also result from a musculoskeletal or hematologic disorder, anxiety, and drug therapy.
Chest pain can arise suddenly or gradually, and its cause may be difficult to ascertain initially. The pain can radiate to the arms, neck, jaw, or back. It can be steady or intermittent, mild or acute. It can range in character from a sharp shooting sensation to a feeling of heaviness, fullness, or even indigestion. It can be provoked or aggravated by stress, anxiety, exertion, deep breathing, or eating certain foods.
Action stat!
Ask the patient when his chest pain began. Did it develop suddenly or gradually? Is it more severe or frequent now than when it first started? Does anything relieve the pain? Does anything aggravate the pain? Ask the patient about associated symptoms. Sudden, severe chest pain requires prompt evaluation and treatment because it may herald a life-threatening disorder. (See Managing severe chest pain, pages 126 and 127.)
History and physical examination
If the chest pain isn't severe, proceed with the history. Ask if the patient feels diffuse pain or can point to the painful area. Ask when the pain began and if the patient ever experienced this type of pain in the past. Sometimes a patient won't perceive the sensation he's feeling as pain, so ask whether he has any discomfort radiating to his neck, jaw, arms, or back. If he does, ask him to describe it. Is it a dull, aching, pressurelike sensation? A sharp, stabbing, knifelike pain? Does he feel it on the surface or deep inside? Ask him to rate the pain on a pain scale. Find out whether it's constant or intermittent. If it's intermittent, how long does it last? Ask if movement, exertion, breathing, position changes, or eating certain foods worsens or helps relieve the pain. Does anything in particular seem to bring it on?
Review the patient's history for cardiac or pulmonary disease, chest trauma, intestinal disease, or sickle cell anemia. Find out which medications he's taking, if any, and ask about recent dosage or schedule changes.
Take the patient's vital signs, noting tachypnea, fever, tachycardia, oxygen saturation, paradoxical pulse, and hypertension or hypotension. Place the patient on a cardiac monitor and evaluate his heart rhythm. Also, look for jugular vein distention and peripheral edema. Note the feel of his skin. Is it cool and clammy or warm and diaphoretic? Auscultate his chest for extra heart sounds. Observe the patient's breathing pattern, and inspect his chest for asymmetrical expansion. Auscultate his lungs for pleural friction rub, crackles, rhonchi, wheezing, or diminished or absent breath sounds. Next, auscultate for murmurs, clicks, gallops, or pericardial friction rub. Palpate for lifts, heaves, thrills, gallops, tactile fremitus, and abdominal masses or tenderness.
Medical causes
Angina pectoris.With angina pectoris, the patient may experience a feeling of tightness or pressure in the chest that he describes as pain or a sensation of indigestion or expansion. The pain usually occurs in the retrosternal region over a palm-sized or larger area. It may radiate to the neck, jaw, and arms—classically, to the inner aspect of the left arm. Angina tends to begin gradually, build to its maximum, and then slowly subside. Provoked by exertion, emotional stress, or a heavy meal, the pain typically lasts 2 to 10 minutes (usually no longer than 20 minutes). Associated findings include dyspnea, nausea, vomiting, tachycardia, dizziness, diaphoresis, belching, and palpitations. You may hear an atrial gallop (a fourth heart sound) or murmur during an anginal episode.
With Prinzmetal's angina, caused by vasospasm of coronary vessels, chest pain typically occurs when the patient is at rest—or it may awaken him. It may be accompanied by shortness of breath, nausea, vomiting, dizziness, and palpitations. During an attack, you may hear an atrial gallop.
Anthrax (inhalation).Inhalation anthrax is caused by inhalation of aerosolized spores. Initial signs and symptoms are flulike and include a fever, chills, weakness, a cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial signs and symptoms. The second stage develops abruptly with rapid deterioration marked by a fever, dyspnea, stridor, and hypotension, generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.
Anxiety.Acute anxiety—or, more commonly, panic attacks—can produce intermittent, sharp, stabbing pain, commonly located behind the left breast. This pain isn't related to exertion and lasts only a few seconds, but the patient may experience a precordial ache or a sensation of heaviness that lasts for hours or days. Associated signs and symptoms include precordial tenderness, palpitations, fatigue, a headache, insomnia, breathlessness, nausea, vomiting, diarrhea, and tremors. Panic attacks may be associated with agoraphobia—fear of leaving home or being in open places with other people.
Aortic aneurysm (dissecting).The chest pain associated with a dissecting aortic aneurysm usually begins suddenly and is most severe at its onset. The patient describes an excruciating tearing, ripping, stabbing pain in his chest and neck that radiates to his upper back, abdomen, and lower back. He may also have abdominal tenderness, a palpable abdominal mass, tachycardia, murmurs, syncope, blindness, loss of consciousness, weakness or transient paralysis of the arms or legs, a systolic bruit, systemic hypotension, asymmetrical brachial pulses, a lower blood pressure in the legs than in the arms, and weak or absent femoral or pedal pulses. His skin is pale, cool, diaphoretic, and mottled below the waist. Capillary refill time is increased in the toes, and palpation reveals decreased pulsation in one or both carotid arteries.
Asthma.In a life-threatening asthma attack, diffuse and painful chest tightness arises suddenly along with a dry cough and mild wheezing, which progress to a productive cough, audible wheezing, and severe dyspnea. Related respiratory findings include rhonchi, crackles, prolonged expirations, intercostal and supraclavicular retractions on inspiration, accessory muscle use, flaring nostrils, and tachypnea. The patient may also experience anxiety, tachycardia, diaphoresis, flushing, and cyanosis.
Blast lung injury.Caused by a percussive shock wave after an explosion, blast lung injury can cause severe chest pain and possibly tearing, contusion, edema, and hemorrhage of the lungs of affected people. Worldwide terrorist activity has recently increased the incidence of this condition, which may also cause dyspnea, hemoptysis, wheezing, and cyanosis. Chest X-rays, arterial blood gas measurements, and computed tomography scans are common diagnostic tools. Although no definitive guidelines exist for caring for those with blast lung injury, treatment is based on the nature of the explosion, the environment in which it occurred, and any chemical or biological agents involved.
Bronchitis.In its acute form, bronchitis produces a burning chest pain or a sensation of substernal tightness. It also produces a cough, initially dry but later productive, that worsens the chest pain. Other findings include a low-grade fever, chills, a sore throat, tachycardia, muscle and back pain, rhonchi, crackles, and wheezing. Severe bronchitis causes a fever of 101º to 102º F (38.3º to 38.9º C) and possible bronchospasm with worsening wheezing and increased coughing.
Cholecystitis.Cholecystitis typically produces abrupt epigastric or right upper quadrant pain, which may be sharp or intensely aching. Steady or intermittent pain may radiate to the back or right shoulder. Commonly associated findings include nausea, vomiting, a fever, diaphoresis, and chills. Palpation of the right upper quadrant may reveal an abdominal mass, rigidity, distention, or tenderness. Murphy's sign—inspiratory arrest elicited when the examiner palpates the right upper quadrant as the patient takes a deep breath—may also occur.
Interstitial lung disease.As interstitial lung disease advances, the patient may experience pleuritic chest pain along with progressive dyspnea, cellophane-type crackles, a nonproductive cough, fatigue, weight loss, decreased exercise tolerance, clubbing, and cyanosis.
Lung abscess.Pleuritic chest pain develops insidiously with a lung abscess along with a pleural friction rub and a cough that raises copious amounts of purulent, foul-smelling, blood-tinged sputum. The affected side is dull to percussion, and decreased breath sounds and crackles may be heard. The patient also displays diaphoresis, anorexia, weight loss, a fever, chills, fatigue, weakness, dyspnea, and clubbing.
Lung cancer.The chest pain associated with lung cancer is commonly described as an intermittent aching felt deep within the chest. If the tumor metastasizes to the ribs or vertebrae, the pain becomes localized, continuous, and gnawing. Associated findings include cough (sometimes bloody), wheezing, dyspnea, fatigue, anorexia, weight loss, and a fever.
Mitral valve prolapse.Most patients with mitral valve prolapse are asymptomatic, but some may experience sharp, stabbing precordial chest pain or precordial ache. The pain can last for seconds or for hours and occasionally mimics the pain of ischemic heart disease. The characteristic sign of mitral prolapse is a midsystolic click followed by a systolic murmur at the apex. Patients may experience cardiac awareness, a migraine headache, dizziness, weakness, episodic severe fatigue, dyspnea, tachycardia, mood swings, and palpitations.
Myocardial infarction (MI).The chest pain during an MI lasts from 15 minutes to hours. Typically a crushing substernal pain unrelieved by rest or nitroglycerin, it may radiate to the patient's left arm, jaw, neck, or shoulder blades. Women are less likely to experience chest pain with an MI, but may complain of pain in the shoulder blade, jaw, and upper back. Other findings include pallor, clammy skin, dyspnea, diaphoresis, nausea, vomiting, anxiety, restlessness, a feeling of impending doom, hypotension or hypertension, an atrial gallop, murmurs, and crackles. Women also complain of fatigue, palpitations, and indigestion.
Pancreatitis.In the acute form, pancreatitis usually causes intense pain in the epigastric area that radiates to the back and worsens when the patient is in a supine position. Nausea, vomiting, a fever, abdominal tenderness and rigidity, diminished bowel sounds, and crackles at the lung bases may also occur. A patient with severe pancreatitis may be extremely restless and have mottled skin, tachycardia, and cold, sweaty extremities. Fulminant pancreatitis causes massive hemorrhage, resulting in shock and coma.
Peptic ulcer.With a peptic ulcer, sharp and burning pain usually arises in the epigastric region. This pain characteristically arises hours after food intake, commonly during the night. It lasts longer than angina-like pain and is relieved by food or an antacid. Other findings include nausea, vomiting (sometimes with blood), melena, and epigastric tenderness.
Pericarditis.Pericarditis produces precordial or retrosternal pain aggravated by deep breathing, coughing, position changes, and occasionally by swallowing. The pain is commonly sharp or cutting and radiates to the shoulder and neck. Associated signs and symptoms include a pericardial friction rub, a fever, tachycardia, and dyspnea. Pericarditis usually follows a viral illness, but several other causes should be considered.
Plague(Yersinia pestis).Signs and symptoms of the plague include fever, chills, and swollen, inflamed, and tender lymph nodes near the site of the flea bite. Septicemic plague develops as a fulminant illness generally with the bubonic form. The pneumonic form may be contracted from person-to-person through direct contact via the respiratory system or through biological warfare from aerosolization and inhalation of the organism. The onset is usually sudden with chills, a fever, a headache, and myalgia. Pulmonary signs and symptoms include a productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.
Pleurisy.The chest pain of pleurisy arises abruptly and reaches maximum intensity within a few hours. The pain is sharp, even knifelike, usually unilateral, and located in the lower and lateral aspects of the chest. Deep breathing, coughing, or thoracic movement characteristically aggravates it. Auscultation over the painful area may reveal decreased breath sounds, inspiratory crackles, and a pleural friction rub. Dyspnea; rapid, shallow breathing; cyanosis; a fever; and fatigue may also occur.
Pneumonia.Pneumonia produces pleuritic chest pain that increases with deep inspiration and is accompanied by shaking chills and fever. The patient has a dry cough that later becomes productive. Other signs and symptoms include crackles, rhonchi, tachycardia, tachypnea, myalgia, fatigue, a headache, dyspnea, abdominal pain, anorexia, cyanosis, decreased breath sounds, and diaphoresis.
Pneumothorax.Spontaneous pneumothorax, a life-threatening disorder, causes sudden sharp chest pain that's severe, typically unilateral, and rarely localized; it increases with chest movement. When the pain is centrally located and radiates to the neck, it may mimic that of an MI. After the pain's onset, dyspnea and cyanosis progressively worsen. Breath sounds are decreased or absent on the affected side with hyperresonance or tympany, subcutaneous crepitation, and decreased vocal fremitus. Asymmetrical chest expansion, accessory muscle use, a nonproductive cough, tachypnea, tachycardia, anxiety, and restlessness also occur.
Pulmonary embolism.A pulmonary embolism produces chest pain or a choking sensation. Typically, the patient first experiences sudden dyspnea with intense angina-like or pleuritic pain aggravated by deep breathing and thoracic movement. Other findings include tachycardia, tachypnea, decreased pulse oximetry, a cough (nonproductive or producing blood-tinged sputum), a low-grade fever, restlessness, diaphoresis, crackles, a pleural friction rub, diffuse wheezing, dullness to percussion, signs of circulatory collapse (a weak, rapid pulse; hypotension), paradoxical pulse, signs of cerebral ischemia (transient unconsciousness, coma, seizures), signs of hypoxia (restlessness) and, particularly in the elderly, hemiplegia and other focal neurologic deficits. Less common signs include massive hemoptysis, chest splinting, and leg edema. A patient with a large embolus may have cyanosis and jugular vein distention.
Q fever.Signs and symptoms of Q fever include a fever, chills, a severe headache, malaise, chest pain, nausea, vomiting, and diarrhea. The fever may last up to 2 weeks. In severe cases, the patient may develop hepatitis or pneumonia.
Sickle cell crisis.Chest pain associated with sickle cell crisis typically has a bizarre distribution. It may start as a vague pain, commonly located in the back, hands, or feet. As the pain worsens, it becomes generalized or localized to the abdomen or chest, causing severe pleuritic pain. The presence of chest pain and difficulty breathing requires prompt intervention. The patient may also have abdominal distention and rigidity, dyspnea, a fever, and jaundice.
Thoracic outlet syndrome.Commonly causing paresthesia along the ulnar distribution of the arm, thoracic outlet syndrome can be confused with angina, especially when it affects the left arm. The patient usually experiences angina-like pain after lifting his arms above his head, working with his hands above his shoulders, or lifting a weight. The pain disappears as soon as he lowers his arms. Other signs and symptoms include pale skin and a difference in blood pressure between both arms.
Tuberculosis (TB).In a patient with TB, pleuritic chest pain and fine crackles occur after coughing. Associated signs and symptoms include night sweats, anorexia, weight loss, a fever, malaise, dyspnea, easy fatigability, a mild to severe productive cough, occasional hemoptysis, dullness to percussion, increased tactile fremitus, and amphoric breath sounds.
Tularemia.Signs and symptoms of tularemia following inhalation of the organism include the abrupt onset of a fever, chills, a headache, generalized myalgia, a nonproductive cough, dyspnea, pleuritic chest pain, and empyema.
Other causes
Chinese restaurant syndrome (CRS).CRS is a benign condition—a reaction to excessive ingestion of monosodium glutamate, a common additive in Chinese foods—that mimics the signs of an acute MI. The patient may complain of retrosternal burning, ache, or pressure; a burning sensation over his arms, legs, and face; a sensation of facial pressure; a headache; shortness of breath; and tachycardia.
Drugs.The abrupt withdrawal of a beta-adrenergic blocker can cause rebound angina if the patient has coronary heart disease—especially if he has received high doses for a prolonged period.
Nursing considerations
▪ Prepare the patient for cardiopulmonary studies, such as an electrocardiogram, chest X-ray, magnetic resonance imaging, and a lung perfusion scan.
▪ Collect a serum sample for cardiac enzyme and electrolyte levels.
▪ Provide emotional support because chest pain produces increased anxiety.
Patient teaching
▪ Explain the purpose and procedure of each diagnostic test to the patient to help alleviate his anxiety.
▪ Teach the patient about the cause of his chest pain once a diagnosis is established.
▪ Explain the purpose of any prescribed drugs, and make sure that the patient understands the dosage, schedule, and possible adverse effects.
▪ Stress the importance of reporting symptoms to allow for the adjustment of treatment.
▪ Teach the patient with coronary artery disease about the typical features of cardiac ischemia as well as the symptoms that should prompt him to seek immediate medical attention.
▪ Discuss lifestyle changes that can reduce the risk of coronary artery disease.
Pictures
Book Source Details
- Book Title: Nursing: Interpreting Signs and Symptoms
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Nursing: Interpreting Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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