Lippincott ® NursingCenter ® Wolters Kluwer Logo

Lippincott NursingCenter Pocket Card - April 2025

Chest Pain Asssessment

icon-howtouse.jpg

Chest Pain Assessment

Patients who present with chest pain can be challenging, as there are so many differential diagnoses to consider. It is imperative to first rule out that the cause is not a result of true cardiac disease. Cardiac disease is the leading cause of death in the United States, yet only 2 to 4 percent of those presenting with chest pain are related to unstable angina or acute myocardial infarction (Patel, 2023). The most common causes of chest pain are chest wall pain, reflux esophagitis, and costochondritis (Patel 2023). To assess chest pain adequately and accurately, a multidisciplinary, measurement-based approach is best.

Causes of Chest Pain (Patel, 2023)

  • Life -threatening causes include acute coronary syndrome, aortic dissection, thoracic aortic aneurysm, cardiac tamponade, tension pneumothorax, cardiac arrhythmias, esophageal rupture/perforation, pulmonary embolism.
  • Non-ischemic causes include heart failure, pericarditis, myopericarditis, myocarditis, stress cardiomyopathy, aortic and mitral valve disease.
  • Other diagnoses that mimic chest pain include:
    • Pulmonary: pneumothorax, sarcoidosis, pneumonia, pleuritis, asthma/chronic obstructive pulmonary disease (COPD), malignancy, pulmonary hypertension, acute chest syndrome/Sickle cell disease
    • Gastrointestinal: gastroesophargeal reflux disease (GERD), esophageal motility disorders, peptic ulcer disease, esophagitis, eosinophilic esophagitis
    • Musculoskeletal: rib pain, rheumatic disease, trauma, isolated musculoskeletal chest pain syndrome
    • Psychiatric: panic disorder, anxiety
    • Drugs of abuse: cocaine, methamphetamines
    • Referred pain
    • Herpes zoster
    • Intimate partner violence

icon-info.jpg

History (White, 2021)

  • Chest pain evaluation starts with a complete history. Begin with a good understanding of their complaint.
  • The chest pain assessment should focus on understanding features of the patient’s pain using the PQRST mnemonic.
    • Provoke: What provokes the pain?
    • Quality: Is the pain dull, sharp, or stabbing?
    • Radiation: Does the pain move to the jaw, neck, or arms?
    • Severity: How severe in the pain (use a pain scale)?
    • Time and Triggering Factors: When and for how long is the pain felt? Ask if the patient has felt this type of pain in the past.
  • Ask about prescribed medications and over-the-counter pain medications.
  • Ask about co-existing medical conditions.
  • Ask about recent falls, trauma, and injuries.
  • Ask about other symptoms including shortness of breath, nausea and vomiting, fever, diaphoresis, cough, dyspepsia, edema, calf pain or swelling, and recent illness.
  • Evaluate for risk factors including prior myocardial infarction, family history of cardiac disease, tobacco use, hypertension, dyslipidemia, diabetes, prior deep venous thrombosis or pulmonary embolism (PE), hormone use, recent surgery, cancer, or periods of non-ambulation, recent gastrointestinal procedures, and drug abuse.

Physical Examination (Johnson, 2022)

  • Full set of vitals, including blood pressure readings obtained from both arms.
  • General appearance, noting diaphoresis and distress.
  • Skin exam for the presence of lesions (e.g., Shingles)
  • Neck exam for jugular venous distension, especially with inspiration
  • Chest, palpate for reproducible pain and crepitus.
  • Heart exam
  • Lung exam
  • Abdominal exam
  • Extremities for unilateral swelling, calf pain, edema, and symmetric, equal pulses
  • Patients with an immediately life-threatening cause for their chest pain tend to appear anxious and distressed and may be diaphoretic and dyspneic.
  • Significant vital sign abnormalities should be addressed immediately.
  • Discrepancies in pulse or blood pressure are notable findings. Signs of dissection include murmur or aortic insufficiency, pulse deficit, signs of shock or cardiac tamponade, heart failure, and cerebrovascular accident.

Diagnosis (Johnson, 2022)

  • Electrocardiogram (ECG) preferably in the first 10 minutes of arrival (consider serial ECGs)     
  • Chest x-ray
  • Complete blood count (CBC), basic metabolic panel (BMP), troponin level (consider serial troponin levels 4 hours apart), lipase.
  • Computed tomography pulmonary angiography (CTPA) if you are considering PE or ventilation-perfusion (VQ) scan if CTPA is contraindicated.
  • Bedside ultrasound (US) if you are considering pericardial tamponade.

Treatment (Johnson, 2022)

  • Acute Coronary syndrome: Place patient on a cardiac monitor, establish intravascular access (IV) access, give 162 mg to 325 mg chewable aspirin, clopidogrel, or ticagrelor (unless bypass surgery is imminent), control pain and consider oxygen (O2) therapy. If ST elevation present, immediate reperfusion therapy, either pharmacologic (thrombolytics) or transfer to the catheterization laboratory for percutaneous coronary intervention (PCI). If non-ST elevation myocardial infarction (NSTEMI) or unstable angina, patient should be admitted for a cardiology consult and workup.
  • Pulmonary embolism (PE): If hemodynamically unstable, start thrombolytics; stable patients should be started on anticoagulants.
  • Pneumothorax: decompressed with a chest tube. 
  • Pericardial tamponade: Needle pericardiotomy or pericardial window to relieve pressure inside the pericardial sack.
  • Aortic dissection: Often immediate surgery is required; consult cardiothoracic surgery early
  • Esophageal perforation: This is a medical emergency, and immediate surgical consult is needed
  • Gastrointestinal reflux disease: Proton pump inhibitor or H2 blocker therapy

Patient Education (White, 2021)

  • Encourage low-fat diet
  • Take nitroglycerin for chest pain
  • Routine exercise
  • Manage medication
  • Lifestyle changes (such as smoking cessation, blood pressure control, and stress management)
  • Schedule regular medical checkups

PEARLS (Johnson, 2022)

  • Younger patients and those without risk factors can still have an MI.
  • People with diabetes and the elderly may have nerve damage which may make it difficult for them to interpret pain. These patients are known to have a more atypical presentation.
 
 
References

Hollander, J. E., Chase, M. (2024, July 30). Approach to the adult with nontraumatic chest pain in the emergency department. UptoDate.  https://sso.uptodate.com/contents/approach-to-the-adult-with-nontraumatic-chest-pain-in-the-emergency-department
 
Johnson, K. (2022, December 14). Chest Pain. Stat Pearls. https://www.ncbi.nlm.nih.gov/books/NBK470557/
 
Patel, H. (2023, Dec 6). Outpatient evaluation of the adult with chest pain. UptoDate. https://sso.uptodate.com/contents/outpatient-evaluation-of-the-adult-with-chest-pain
 
White, A.J. (2021, September 2). Myocardial infarction: Nursing assessment and care. American Nurse. https://www.myamericannurse.com/myocardial-infarction-nursing-assessment-and-care/ 
 

Download this Tip:

CE Resources

Nursing Resources

About NursingCenter

 

© 2025 Wolters Kluwer Health, Inc. and/or its subsidiaries. All rights reserved. – Terms & Conditions – Privacy Policy – Disclaimer – Your California Privacy Choices -- v10.02.00