Chest pain
Disorders that affect thoracic or abdominal organs — the heart, pleurae, lungs, esophagus, rib cage, gallbladder, pancreas, or stomach — are typical causes of chest pain. It can also result from a musculoskeletal or hematologic disorder, anxiety, and drug therapy. Chest pain is an important indicator of several acute and life-threatening cardiopulmonary and GI disorders.
The onset of chest pain can be sudden or gradual, and its cause may initially be difficult to ascertain. Chest pain can radiate to the arms, neck, jaw, or back. It can be steady or intermittent, mild or acute. And it can range in character from a sharp shooting sensation to a feeling of heaviness, fullness, or even indigestion. Chest pain can be provoked or aggravated by stress, anxiety, exertion, deep breathing, or eating certain foods.
Act Now: Sudden, severe chest pain requires prompt evaluation and treatment because it may herald a life-threatening disorder. (See Managing severe chest pain, pages 76 and 77.) Standardized algorithms are used to address the treatment regimen of the patient with chest pain. Determine the time of onset and whether it was sudden or gradual. Ask the patient about precipitating, alleviating, or aggravating factors, if the pain radiates, and associated signs and symptoms. Ask him to rate the pain using a standardized pain rating scale. Obtain a 12-lead electrocardiogram (ECG) and a blood sample for serum testing. Administer oxygen through a nasal cannula. Place the patient on a cardiac monitor and establish I.V. access. If test results indicate an acute myocardial infarction (MI), the patient will require emergency percutaneous coronary intervention or fibrinolytic therapy. Be prepared to administer emergency care if the patient experiences cardiopulmonary arrest.
Assessment
History
Ask the patient to rate the pain using a standardized pain rating scale. Is the pain a dull, aching, pressurelike sensation, or sharp, stabbing, and knifelike? Is it constant or intermittent? If it’s intermittent, ask how long an episode lasts. Ask him about precipitating, aggravating, or alleviating factors. Review the patient’s history for cardiac or pulmonary disease, chest trauma, intestinal disease, or sickle cell anemia. Ask about medications he’s taking, if any, including recent dosage or schedule changes.
ALERT: Chest pain in perimenopausal women may be difficult to diagnose because it may present atypically. Fatigue, nausea, dyspnea, and shoulder or neck pain are symptoms more likely to signal an MI in women than in men.
Physical examination
Take the patient’s vital signs, noting tachypnea, fever, tachycardia, oxygen saturation, paradoxical pulse, and hypertension or hypotension. Check for jugular vein distention and peripheral edema. 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.
Pediatric pointers
Even a child old enough to talk may have difficulty describing chest pain, so stay alert for nonverbal clues, such as restlessness, facial grimaces, or holding the painful area. Ask the child to point to the painful area and then to where the pain goes (to find out if it’s radiating). Assess the severity of the pain by asking the parents whether the pain interferes with the child’s normal activities and behavior. Remember, a child may complain of chest pain in an attempt to get attention or to avoid attending school.
Geriatric pointers
Remember to carefully evaluate chest pain in elderly patients, who have a higher risk of developing life-threatening conditions, such as an MI, angina, and aortic dissection.
Medical causes
See Chest pain: Causes and associated findings, pages 78 to 81.
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 is an acute infectious disease that’s caused by the gram-positive, spore-forming bacterium Bacillus anthracis. Although the disease most commonly occurs in wild and domestic grazing animals, such as cattle, sheep, and goats, the spores can live in the soil for many years. The disease can occur in humans exposed to infected animals, tissue from infected animals, or biological warfare. Most natural cases occur in agricultural regions worldwide, and it may occur in cutaneous, inhalation, and GI forms.
Inhalation anthrax is caused by inhalation of aerosolized spores. Initial signs and symptoms are flulike and include fever, chills, weakness, 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 fever, dyspnea, stridor, and hypotension, generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.
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, 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 aortic aneurysm — a life-threatening disorder — 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 exhibit 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, 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.
Blastomycosis.
Besides pleuritic chest pain, blastomycosis initially produces signs and symptoms that mimic those of viral upper respiratory tract infection: a dry, hacking, or productive cough (and sometimes hemoptysis), fever, chills, anorexia, weight loss, fatigue, night sweats, and malaise.
In its acute form, bronchitis produces 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 low-grade fever, chills, sore throat, tachycardia, muscle and back pain, rhonchi, crackles, and wheezing. Severe bronchitis causes a fever of 101° to 102° F (38.3° to 38.9° C) and possible bronchospasm with worsening wheezing and increased coughing.
With hypertrophic cardiomyopathy, angina-like chest pain may occur with dyspnea, cough, dizziness, syncope, gallops, murmurs, and bradycardia associated with tachycardia.
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, 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.
Coccidioidomycosis.
With coccidioidomycosis, pleuritic chest pain occurs with a dry or slightly productive cough. Other effects include fever, rhonchi, wheezing, occasional chills, sore throat, backache, headache, malaise, marked weakness, anorexia, and macular rash.
Costochondritis.
Pain and tenderness occur at the costochondral junctions, especially at the second costicartilage. The pain usually can be elicited by palpating the inflamed joint.
Central chest pain may radiate to the left arm in patients with distention of colon’s splenic flexure. The pain may be relieved by defecation or passage of flatus.
With esophageal spasm, substernal chest pain may last up to an hour and can radiate to the neck, jaw, arms, or back. It commonly mimics angina — a squeezing or dull sensation. Associated signs and symptoms include dysphagia for solid foods, bradycardia, and nodal rhythm.
The pain of pre-eruptive herpes zoster may mimic that of an MI. Initially, the pain is characteristically sharp, shooting, and unilateral. About 4 to 5 days after its onset, small, red, nodular lesions erupt on the painful areas — usually the thorax, arms, and legs — and chest pain becomes burning. Associated findings include fever, malaise, pruritus, and paresthesia or hyperesthesia of the affected areas.
Typically, hiatal hernia produces an angina-like sternal burning (heartburn), ache, or pressure that may radiate to the left shoulder and arm. The discomfort commonly occurs after a meal when the patient bends over or lies down. Other findings include a bitter taste and pain while eating or drinking, especially hot drinks and spicy foods.
As interstitial lung disease advances, the patient may experience pleuritic chest pain along with progressive dyspnea, cellophane-type crackles, nonproductive cough, fatigue, weight loss, decreased exercise tolerance, clubbing, and cyanosis.
Legionnaires’ disease.
Legionnaires’ disease produces pleuritic chest pain, in addition to malaise, headache and, possibly, diarrhea, anorexia, diffuse myalgia, and general weakness. Within 12 to 24 hours, the patient develops a sudden high fever, chills, and a nonproductive cough that progresses to mucoid and then to mucopurulent sputum, possibly with hemoptysis. Patients may also experience flushed skin, mild diaphoresis, prostration, nausea and vomiting, mild temporary amnesia, confusion, dyspnea, crackles, tachypnea, and tachycardia.
Pleuritic chest pain develops insidiously in lung abscess along with a pleural friction rub and cough that raises copious amounts of purulent, foul-smelling, blood-tinged sputum. The affected side is dull on percussion, and decreased breath sounds and crackles may be heard. The patient also displays diaphoresis, anorexia, weight loss, 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 fever.
Mediastinitis.
Mediastinitis produces severe retrosternal chest pain that radiates to the epigastrium, back, or shoulder and may worsen with breathing, coughing, or sneezing. Its accompanying signs and symptoms include chills, fever, and dysphagia.
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 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. The patient may experience cardiac awareness, migraine headache, dizziness, weakness, episodic severe fatigue, dyspnea, tachycardia, mood swings, and palpitations.
Strained chest, arm, or shoulder muscles may cause a superficial and continuous ache or “pulling” sensation in the chest. Lifting, pulling, or pushing heavy objects may aggravate this discomfort. With acute muscle strain, the patient may experience fatigue, weakness, and rapid swelling of the affected area.
Myocardial infarction (MI).
The chest pain during an MI lasts from 15 minutes to hours. Typically, crushing substernal pain, unrelieved by rest or nitroglycerin, may radiate to the patient’s left arm, jaw, neck, or shoulder blades. Other findings include pallor, clammy skin, dyspnea, diaphoresis, nausea, vomiting, anxiety, restlessness, a feeling of impending doom, hypotension or hypertension, atrial gallop, murmurs, and crackles.
Nocardiosis causes pleuritic chest pain with a cough that produces thick, tenacious, purulent or mucopurulent, and possibly blood-tinged sputum. Nocardiosis may also cause fever, night sweats, anorexia, malaise, weight loss, and diminished or absent breath sounds.
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, 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 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 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 pericardial friction rub, fever, tachycardia, and dyspnea. Pericarditis usually follows a viral illness, but several other causes should be considered.
Plague is an acute bacterial infection caused by
Yersinia pestis. It’s one of the most virulent infections and, if untreated, one of the most potentially lethal diseases known. Most cases are sporadic, but the potential for epidemic spread still exists. Clinical forms include bubonic (the most common), septicemic, and pneumonic plagues. The bubonic form is transmitted to man when bitten by infected fleas. Signs and symptoms include fever, chills, and swollen, inflamed, and tender lymph nodes near the site of the fleabite. 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, fever, headache, and myalgia. Pulmonary signs and symptoms include productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.
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, fever, and fatigue may also occur.
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, headache, dyspnea, abdominal pain, anorexia, cyanosis, decreased breath sounds, and diaphoresis.
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, nonproductive cough, tachypnea, tachycardia, anxiety, and restlessness also occur.
Psittacosis.
Psittacosis may produce pleuritic chest pain on rare occasions. It typically begins abruptly with chills, fever, headache, myalgia, epistaxis, and prostration.
Pulmonary actinomycosis causes pleuritic chest pain with a cough that’s initially dry but later produces purulent sputum. The patient may also display hemoptysis, fever, weight loss, fatigue, weakness, dyspnea, and night sweats. Multiple sinuses may extend through the chest wall and drain externally.
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, cough (nonproductive or producing blood-tinged sputum), low-grade fever, restlessness, diaphoresis, crackles, pleural friction rub, diffuse wheezing, dullness on percussion, signs of circulatory collapse (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.
Angina-like pain develops late in patients with pulmonary hypertension, usually on exertion. The precordial pain may radiate to the neck but doesn’t characteristically radiate to the arms. Typical accompanying signs and symptoms include exertional dyspnea, fatigue, syncope, weakness, cough, and hemoptysis.
Q fever is a Rickettsial disease caused by
Coxiella burnetii. The primary source of human infection results from exposure to infected animals. Cattle, sheep, and goats are most likely to carry the organism. Human infection results from exposure to contaminated milk, urine, feces, or other fluids from infected animals. Infection may also result from inhalation of contaminated barnyard dust.
C. burnetii is highly infectious and is considered a possible airborne agent for biological warfare. Signs and symptoms include fever, chills, severe headache, malaise, chest pain, nausea, vomiting, and diarrhea. The fever may last for up to 2 weeks. In severe cases, the patient may develop hepatitis or pneumonia.
The chest pain due to fractured ribs is usually sharp, severe, and aggravated by inspiration, coughing, or pressure on the affected area. Besides shallow, splinted respirations, dyspnea, and cough, the patient experiences tenderness and slight edema at the fracture site.
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, fever, and jaundice.
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.
In a patient with tuberculosis, pleuritic chest pain and fine crackles occur after coughing. Associated signs and symptoms include night sweats, anorexia, weight loss, fever, malaise, dyspnea, easy fatigability, mild to severe productive cough, occasional hemoptysis, dullness on percussion, increased tactile fremitus, and amphoric breath sounds.
Also known as
rabbit fever, tularemia is caused by the gram-negative, non-spore forming bacterium
Francisella tularensis. It’s typically a rural disease found in wild animals, water, and moist soil. It’s transmitted to humans through the bite of an infected insect or tick, handling infected animal carcasses, drinking contaminated water, or inhaling the bacteria. It’s considered a possible airborne agent for biological warfare. Signs and symptoms following inhalation of the organism include the abrupt onset of fever, chills, headache, generalized myalgia, nonproductive cough, dyspnea, pleuritic chest pain, and empyema.
Other causes
Chinese restaurant syndrome, which stems from a reaction to excessive ingestion of monosodium glutamate (a common additive in Chinese foods), is
a benign condition 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; headache; shortness of breath; and tachycardia.
Drugs.
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
As needed, prepare the patient for cardiopulmonary studies, such as an ECG and a lung scan. Perform a venipuncture to collect a serum sample for cardiac enzyme and other studies. Assess the cardiovascular system frequently. Interpret changes in cardiac rhythm. Be prepared for emergency procedures.
Keep in mind that a patient with chest pain may deny his discomfort, so stress the importance of reporting symptoms to allow adjustment of his treatment.
Patient teaching
Explain the purpose and procedure of each diagnostic test to the patient to help alleviate his anxiety. Prepare him if cardiac catheterization or fibrinolytic therapy is indicated. Explain the purpose of any prescribed drugs and make sure that he understands the dosage, schedule, and possible adverse effects. Teach the patient with coronary artery disease to recognize the typical features of cardiac ischemia as well as symptoms that require prompt medical attention. Teach him how to administer sublingual nitroglycerin and advise him to seek medical attention if the pain lasts more than 20 minutes, fails to respond to nitroglycerin, or has a different pattern than the usual angina.
Pictures
Book Source Details
- Book Title: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2008 Williams & Wilkins.
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Chest pain (Signs & Symptoms: A 2-in-1 Reference for Nurses)
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