Post operative chest pain
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This document provides guidance on evaluating and summarizing the potential causes of post-operative chest pain in 3 sentences or less: The most common causes of post-operative chest pain are cardiac, pulmonary, gastric, or musculoskeletal in nature. It is important to take a detailed history regarding the pain's characteristics, aggravating/alleviating factors, and associated symptoms. A thorough physical exam including vital signs, cardiac/pulmonary exam, abdominal exam and extremities can help identify potential etiologies and guide further evaluation or treatment.
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Post operative chest pain
- 1. Post Operative Chest Pain: Eliciting the underlying cause Raymond Zakhari, NP www.MetroMedicalDirect.com
- 2. Most Common Etiologies Cardiac Pulmonary Gastric Musculo-skeletal
- 3. History: Key questions to ask Where is the pain or pressure located? Point with one finger Use the same words back to the patient when assessing, reassessing, and documenting It is very important to clearly elicit what the patient means by the word pain Sharp Dull Aching Burning
- 4. Detailed history: Quality Quantify the pain or pressure 1-10 scale? What is it at its worst? What is it at its best? Is it tolerable? Repeat this after each intervention Have you ever had this pain or pressure before? Tell me about that time What was done about it? Is there anything different about this incident from the last time?
- 5. Detailed History: Character Is the pain constant or intermittent? How long between episodes of pain? How long does each episode last? Is each episode getting progressively better or worse? How long have you been experiencing this episode of pain? Are there any other associated symptoms with this? Nausea Vomiting Dizziness Numbness/ tingling Sweating Itching Sense of impending doom Anxiety Bad or sour taste in your mouth Does the pain radiate? Jaw Neck Teeth Shoulder Nose Eyes
- 6. Detailed History: Aggravating & Alleviating Factors Does anything make the pain better or worse? Movement Reaching Walking Position changes Touching the site of pain Breathing
- 7. Physical Exam: Vital Signs Apical Heart Rate compared to Radial Pulse for 1 minute Check peripheral pulses compare to baseline quality Respiratory Rate including depth and pattern Blood pressure compared to baseline Oxygen Saturation (hand should be covered, and heart rate should correlate) Oral Temperature Finger Stick Blood glucose
- 8. Physical Exam: Neuro & Psych Is the person Awake, Alert & oriented to person, time, place and purpose? Are they speaking in normal voice? Rate of speech? Organized thought progression? Appropriate answers to simple questions? Able to follow commands?
- 9. Physical Exam: Cardiac & Pulmonary Lung Sounds and Effort Clear and unlabored vs. crackles with accessory muscle use? Does the patient assume a certain posture to help with breathing? How many balls can they raise on the incentive spirometer compared to previous? Are the neck veins distended? Are all pulses symmetrical and palpable
- 10. Physical Exam: Abdomen/ Extremities Is there Abdominal Distension? Hyperactive bowel sounds Is there any swelling, heat or discoloration of an extremity? Is this bilateral or unilateral? Is it a change from baseline? Is there an obvious external cause? Immobility Tourniquet, ID bracelet, BP cuff, compression device, ice pack, heat pack
- 11. Clinical Characteristics: Cardiac etiology Pain is often called pressure +/- Radiating (Vagus Nerve Innervation post cardiac transplant patients usually do not radiate ) +/- nausea or vomiting +/- Lightheadedness +/- Numbness/ tingling +/- Sweating Last longer than 5 minutes Episodes should be triggered by exertion Constant while at rest Not made better or worse by palpation or reaching
- 12. Clinical Characteristics: Pulmonary Embolus Chest pain worse with deep breathing Low or downward trending SpO2 Tachycardia or heart rate trending upward (minus other causes) Patient becoming restless or agitated Risk factors present (history of clots, long travel, normally on anticoagulant)
- 13. Clinical Characteristics: Gastric related chest pain/ pressure Pain is changed (usually improved) by positioning, palpation, movement Abdominal distension Associated bloating Eructating and passing flatus Acidic taste or sour taste in mouth Associated heart burn or history of reflux
- 14. Clinical characteristics: Musculoskeletal Chest Pain Pain is made worse with movement Pressing on a certain point makes pain worse Patient is guarded in their movement Topical agents relieve the pain (heat rub, ice pack etc.) No other associated symptoms and or history of recent/ remote trauma
- 15. When in doubt: Take a History and Physical Check a complete set of Vital Signs HR, BP, RR, T, SpO2, Finger stick (low blood sugar can cause anxiety and somatization and altered mental status) Do a 12 Lead ECG Page the NP, Primary Team If no response or decompensating call Rapid Response (44444)