0819: The client reports feeling "tightness in the chest" for the last 30 minutes. The pain came on suddenly while he was in bed. He describes the pain as a pressure-like sensation radiating to his left arm. He states that the pain is 'severe.' The pain does not improve with rest or changing positions. The client reported one year ago, he had this chest pain that was relieved with nitroglycerin. Upon assessment, the client was anxious and had a flushed appearance. Clear lung sounds bilaterally. Peripheral pulses 2+. Physician was called to the triage room where verbal orders were received. Medical history of diabetes mellitus (type two), hypertension, and hyperlipidemia.
- 12-lead electrocardiogram (ECG)
- serum troponin
12-lead electrocardiogram (ECG): Shows ST-segment depression in leads V4-V6.
Serum Troponin T: 0.15 ng/mL (< 0.1 ng/mL).
The nurse reviews the client's assessment findings and considers if it aligns with unstable angina and/or stable angina.
➢ For each assessment finding below, click to specify if the finding is consistent with the condition of stable angina or unstable angina. Each finding may support more than one (1) disease process.
- A. Location of pain
- B. Onset of pain
- C. ECG findings
- D. Pain intensity
- E. Duration of pain
- F. Medical history
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