Nurse Practitioner

CLINICAL PROTOCOL
Chest Pain
INTRODUCTION: Patients presenting with chest pain require rapid evaluation. Myocardial
ischaemia should be considered in all patients presenting with chest pain. Assessment of
pain type and referral, and response of pain to various interventions is important in
differentiating between cardiac and non-cardiac chest pain. If the pain is cardiac in nature it
is important to respond quickly to ensure the best possible outcome for the Pt.
DIFFERENTIAL DAIGNOSIS:
CVS CAUSES; AMI, unstable angina, aortic dissection, aortic aneurysm, pericarditis,
aortic stenosis, mitral valve prolapse.
RESP CAUSES; pulmonary embolism, pneumothorax, severe pneumonia.
GI CAUSES; oesophageal spasm or rupture, gastric reflux, indigestion, perforated
peptic ulcer.
Musculoskeletal causes.
Trauma or neoplasm.
Psychiatric causes.

CLINICAL PRACTICE GUIDELINE

Nurse
Practitioner

Scope
Chest pain responsive to protocols
outlined within this CP.

Medical
Chest pain unresponsive to treatment
Practitioner
outlined within this CP.
+/ Evidence/suspicion of AMI or more
Nurse
serious cause of pain.
Practitioner
Initial Assessment and Interventions
Presenting
Relevant past medical Hx and
History
medication history
Known allergies
Pt. describes pain as squeezing,
pressing, constricting, and heavy in
central chest, +/- radiating to left
arm, neck or jaw.
Pt. may feel a sense of impending
doom.

Outcomes
Identify patients suitable for
NP clinical protocol. Refer
unsuitable pts. to current GP.
Identify patients not suitable
for NP CP and redirect to usual
GP care +/- ED
Outcomes
Identify patients not suitable
for NP CP and redirect to usual
GP care +/- ED

Nurse Practitioner
CLINICAL PROTOCOL
Chest Pain
Physical
examination

Primary survey ABC

Vital signs (T, P, R, BP), ECG if
available. Signs of ST elevation
refer GP/ED for thrombolysis.
Assess pain: time of onset, position
of pain including any radiation,
description of pain, severity of pain,
length of time pain has been present,
frequency of pain episodes, what
were you doing when the pain
started, does anything make it better
or worse, is it reproducible by
palpation
Any nausea, epigastric discomfort?
Note any diaphoresis.
Any SOB or dizziness
Is the Pt. pale?
Be aware of atypical signs/symptoms:
No chest pain, but pain related to
exertion or stress in the left arm or
jaw.
Epigastric discomfort.
Unexplained fatigue.
Indigestion, belching.
Dizziness
Pain in the right arm.
Confusion.
Assess associated vascular risk
factors (eg strong family Hx).

Identify patients not suitable

for NP CP exit CP and refer
to current GP.

Pain
assessment

Asses level of pain using appropriate pain

scale. Morphine 2.5 5mg IV then titrate to
effect if required (GP only).

Determine need for and type of

analgesia required.

Pathology

Imaging

Investigations
Troponin, FBC, U&E, CK, LFTs
CXR if respiratory cause suspected.

Patient Education / Follow-up

Follow up
Verbal instruction to patient:
appointment
Review appointment may be indicated
by pathology results; NP to contact
patient to schedule follow-up

Outcomes
Refer to GP for ongoing
management.
Diagnosis of cause of pain and
application of correct treatment
regime.
Outcomes
Ensure patient understands
problem, treatment and follow
up.

Nurse Practitioner
CLINICAL PROTOCOL
Chest Pain
appointment.
Patient
Education

Verbal instruction and patient information

handout if required and appropriate.

Patient understanding of the

problem, treatment and
measures which may reduce
the risk of ongoing
complications.
Medication
Verbal/written instructions from NP/GP Ensure patient understands
problem, treatment and follow
instructions
up
Referrals
Referrals may be required for specific patient
Patients with problems outside
problems or as required to:
the NPs scope of practice are
Physiotherapy
referred to appropriate health
Drug and alcohol counsellor
care providers.
Other problems outside of NP scope of
practice
Ensure appropriate
Certificates
Absence from work certificates
Certificate of attendance
documentation completed
Letter
Copy of notes to GP / Specialist or
Ensure continuity of care and
acute care facility
referral to health care team
GP hospital admission
Interpretation of results and management decisions
Outcome
All medications will be stored, labelled and dispensed in accordance with hospital policy and relevant legislation

Nurse
e Practition
ner
CLINICA
AL PROTO
OCOL
Ch
hest Pain
Inittial
manag
gement
path
hway

Reassu
ure Pt.

Plac
ce Pt. in an upright
u
positio
on
Give O2 2-4 L/nasal cannula
c
if available.

Assess vital signs (ECG if availa

able)
Assess ch
hest pain

If no resp
ponse to glyc
ceryl
trinitrate
refer to cu
urrent GP
for further advice and
d
ment.
managem
eriences a cardiac
c
If Pt. expe
arrest commence
c
b
basic
life
support/a
advanced life
e support
as per fac
cility protoco
ol.
r
to
Documenttation and referral
current GP, transfer to
t nearest
cy departme
ent.
Emergenc

er sublingual glyceryl triniitrate as

Administe
prescrribed
Assess vittal signs

Iff no response
e after 5 mins
s
Repea
at sublingual glyceryl trinittrate
Assess vittal signs

Iff no response
e after 5 mins
s
Repea
at sublingual glyceryl trinittrate
Assess vittal signs

If pain is unresolv
ved after 20 mins
m
(3 doses of glyc
ceryl trinitrate
e)
CAL
LL 000 FOR AN
A AMBULANC
CE

Administer 300mgs Aspirin

n
R
Reassess
Pt. every
e
5 mins

Administer analg
gesia if requ
uired
y if necessa
ary
Maintain airway
C
Continue
to reassure
r
Pt..

Nurse Practitioner
CLINICAL PROTOCOL
Chest Pain

Goals of Treatment
Relief of symptoms

Prevention of recurrence

Prevention of complications

Drug Formulary

FORMULARY
GLYCERYL TRINITRATE

ASPIRIN

Drug (generic name): Glyceryl Trinitrate

Drug (generic name): Aspirin

Dosage range: 400 mgs (spray) OR 600microgram (tablet)

Dosage range: 150 - 300mg

Route: oral (sublingual)

Route: oral

Frequency of administration: 5 minutely if pain persists

Frequency of administration: immediately

Duration of order: as required max of 3 metered doses, or 3

Duration of order: single dose

tablets (1800 micrograms).

Actions: immediate antiplatelet effect, produces complete

Actions: Venodialting effects, reduction in venous return and

inhibition of thromboxane-mediated platelet aggregation

preload to the heart therefore reducing myocardial oxygen

within 30 minutes.

requirement.

Indications for use: Acute chest pain with suspicion of acute

Indications for use: Prevention and treatment of angina,

coronary syndrome.

acute heart failure associated with MI.

Contraindications for use: Known NSAID hypersensitivity

Contraindications for use: hypovolaemia, raised ICP, G6PD

(esp. asthma).

deficiency (risk of haemolytic anaemia).

Adverse drug reactions: bleeding, GI upset,

Adverse drug reactions: headache, flushing, palpitations,

fainting, peripheral oedema. Rarely rebound angina.

Unexpected
representation
NP Clinical
Practice

Evaluative strategies
Review Patient Notes. Full audit of clinical
events.
NP Clinical Practice/Medical Report Audit

Nurse Practitioner
CLINICAL PROTOCOL
Chest Pain
Key Terms
NP Nurse Practitioner
CP Clinical Protocol
GP General Practitioner
S4 Schedule of the drug administration
act
References
1. Australian Medicines handbook (internet). 2011, Nov. Accessed 2011 Dec 1 at
http://www.amh.net.au
2. etg complete (internet). Melbourne: Therapeutic Guidelines Limited; 2011 Nov.
Accessed 2011 Dec 1 at http://etg.tg.com.au/ref/ref
Authorship, Endorsement and acknowledgement
This CP was originally written by:
Reviewed and authorised by:
Carol Jones
Dr. Frank Reedman Jones
Nurse Practitioner
MBBCh, DCH, DRCOG, FRACGP, FACRRM
Murray Medical Centre Mandurah
Murray Medical Centre: Primary Care

Physician

We acknowledge the authorship and

input of :

Dr. Eileen Bristol

MBChB,MRCGP,DRCOG,FRACGP
Murray Medical Centre: Primary Care
Physician
Carol Jones
RN, RM, PGradDipNursePractitioner, NP
Nurse Practitioner

Date Written: November 2011

Review Date: November 2013