Nursing ON CLIENTS WITH EMERGENCY
Chest pain
1. UNDERSTANDING
* Chest pain is the feeling of pain / uncomfortable and disturbing the chest area is often a pain that is projected on the chest wall (Referred pain)
* Coroner Pain is pain due to myocardial ischemia due to coronary blood flow supply at a time is insufficient for the needs of myocardial metabolism.
* Chest pain caused by lung diseases such as inflammation of the pleura (pleuritis), because lung lining that can be a source of pain, moderate visceral pleura and lung parenchyma painless (Himawan, 1996)
*Etiology
Chest pain:
1. Cardial
- Coronary
- Non-Coronary
2. Non Cardial
- Pleural
- Gastrointestinal
- Neural
- Psychogenic (N Abdurahman, 1999)
*. SIGNS AND SYMPTOMS
Signs and symptoms that accompany chest pain are common:
- Heartburn
- Headaches
- Pain that is projected onto the arm, neck, back
- Diaforesis / cold sweat
- Shortness of breath
- Tachycardia
- Pale skin
- Difficulty sleeping (insomnia)
- Nausea, vomiting, anorexia
- Anxious, nervous, focus on yourself
- Weakness
- Face tense, m erintih, crying
- Changes in consciousness
*. EXAMINATION SUPPORT
1. 12 lead ECG during pain episode
- Takhikardi / dysrhythmias
- Record full ECG: T inverted, ST elevation / depression, pathological Q
2. Laboratory
- Levels of cardiac enzymes: CK, CKMB, LDH
- Liver function: SGOT, SGPT
- Kidney function: U, creatinin
- Lipid profile: LDL, HDL
3. Photo Thorax
4. Echocardiografi
Third. Cardiac catheterization
*. ASSESSMENT
1. Primary Assessment
1. Airway
- How kepatenan airway
- Is there a blockage / congestion in the airway secretions?
- How is the sound of his breathing, if there is an additional breath sounds?
2. Breathing
- How is her breathing pattern? Frequency? The depth and rhythm?
- Are there using respiratory muscle aids?
- Are there additional breath sounds?
3. Circulation
- What about the peripheral arteries and carotid arteries? The quality (content and voltage)
- How capillary refill, whether there akral cold, cyanosis or oliguri?
- Is there a decrease in consciousness?
- How any vital signs? T, S, N, RR, HR?
*. Secondary Assessment
The important points that need further examination during chest pain (coronary):
1. Location of pain
Where is the start, penjalarannya (coronary chest pain: from the sternal spread to the neck, chin or shoulder to the left arm of the ulna)
2. Nature of pain
Feeling full, heavy feeling like cramp, squeeze, stab, strangle / burning sensation, etc..
3. Pain characteristics
The degree of pain, duration, how often arise within a certain timeframe.
4. Chronological pain
Early pains and development arise sequentially
. Condition at the time of attack
Does arise in times / circumstances
. Factors that reinforce / relieve pain such as attitude / body position, movement, pressure, etc..
. Other symptoms may be whether there is any correlation with chest pain.
**. Nursing Diagnosis
1. Changes in the comfort of pain (acute pain)
2. Changes in tissue perfusion (heart muscle)
Third.
1. Nursing INTERVENTION
Principles of Action:
1. bedrest with Fowler position semi Fowler
2. Perform 12 lead EKG if necessary 24 leads
Third. Observe vital signs
4. Collaboration of O2 and the administration of drugs-analgesics, tranquilizers, nitroglycerin, calcium antagonists, and observations of drug side effects.
5. Inserting an IV and give peace to clients
6. Taking blood samples
7. Reduce environmental stimuli
8. Be calm in the works
9. Observe the signs of complications
(Nursing diagnoses, signs and symptoms etc are not always equal what is delivered at the patient’s chest pain, this is just an overview, do not dwell on what above)
|
Related nursing
Share this Post[?]
