A patient admitted in ward with prior MI attack. He complains of chest pain, what is the first action of the… - AIIMS Rishikesh & Jodhpur NO - 2017

AIIMS Rishikesh & Jodhpur NO - 2017

Medical & Surgical Nursing

Medium

Appeared in: AIIMS Rishikesh & Jodhpur NO - 2017

Explanation

The nursing process (Assessment, Diagnosis, Planning, Implementation, Evaluation - ADPIE) dictates that assessment is always the first step in patient care.
A thorough pain assessment (e.g., using PQRST) is required to gather critical data about the chest pain, which helps differentiate its cause (e.g., cardiac vs. non-cardiac).
This initial assessment provides a crucial baseline against which the effectiveness of subsequent interventions can be measured.
Acting before assessing can lead to errors, such as administering a medication that is contraindicated by the patient's current vital signs (e.g., giving nitroglycerin to a hypotensive patient).

Option A: This is an implementation step. Administering nitroglycerin without first assessing the pain and checking the patient's blood pressure is unsafe. Nitroglycerin is a potent vasodilator and can cause severe hypotension.
Option B: This is a reporting/collaboration step. While important, it should be done after a quick but thorough assessment. The nurse needs to provide the doctor with specific information (e.g., vital signs, pain characteristics) to facilitate effective decision-making.
Option D: This action is negligent and dangerous. Chest pain in a patient with a known history of MI must always be treated as a potential cardiac emergency until proven otherwise. Ignoring it can lead to significant morbidity or mortality.

Clinical Relevance

Nursing practice connection: Use the key finding related to Prioritization of Nursing Actions in Acute Chest Pain to guide bedside assessment, documentation, and the next nursing action.
The 'Assess Before You Act' principle is a cornerstone of safe nursing practice, especially in emergencies. It prevents premature interventions that could harm the patient.
In a patient with a history of MI, chest pain is considered unstable angina or reinfarction until proven otherwise. Prompt and correct assessment is key to early intervention and improved outcomes.
What if? If the initial assessment revealed a blood pressure of 85/50 mmHg, the nurse would withhold nitroglycerin (as it would worsen hypotension) and immediately inform the physician, highlighting the low blood pressure as a critical finding.

How to Approach the Question

Identify the question type: This is a priority-based question asking for the 'first action'.
Recall the nursing process (ADPIE): Assessment, Diagnosis, Planning, Implementation, Evaluation. The first step is always Assessment.
Analyze the options in the context of ADPIE. 'Assess the characteristic of the pain' is the only option that falls under the Assessment step.
Eliminate intervention options ('Provide nitroglycerin') and reporting options ('Inform doctor') as they come after assessment.
Eliminate any option that dismisses a potentially serious symptom ('It is normal, avoid it'), as this contradicts the principle of patient safety.

Concept Tested & Keywords

Concept Tested: Prioritization of Nursing Actions in Acute Chest Pain
Stem keywords: prior MI, chest pain, first action, on-duty nurse
Lead-in keywords: first action
Clinical cues: A history of MI is a significant risk factor, making any new chest pain a high-priority complaint that could indicate reinfarction or unstable angina.