GTN Spray Sample Script Guide
Scenario: The patient rang the bell complaining of chest pain. The patient is sitting on the chair.
Entered the patient's room and did my hand hygiene. Introduced myself to the patient as a staff nurse.
Nurse: Hi, how are you? I heard you rang the bell. Can I help you?
Patient: I am having a chest pain nurse.
*Transfer the patient to bed and sit upright with pillows at the back.
* Identify the Patient or Verify MRN (Medical Record Number)
* Assess Pain using OPQRST (Onset, Provocation, Quality, Radiation, Severity, Time)
*Get quick observation especially the Blood Pressure (Do not give GTN Spray if BP is below 90/60
mmHg)
* Assessor asked before what artery was affected - Coronary Artery.
**IF ASSESSOR KEEP ASKING TO GIVE MEDS WHILE TAKING OPQRST. Be assertive that you need to do
proper assessment before giving you the medication for proper medicine management**
Double check order of GTN Spray with a colleague and mention observation of the patient especially
pain score and blood pressure.
Order : Glyceryl trinitrate or GTN Spray 800 mcg, Sublingual, PRN for chest pain
Stock dose 400 mcg/ spray, so you need to give 2 sprays
* Check quality (package intact and check expiry)
* Explain to the patient what the medicine is for (explain that this meds will help to relax the muscle of
your heart, widens the blood vessels and hopefully will relieve the chest pain) and do read more about
the medication.
* Explain the side effect (medication can cause dizziness, lightheadedness and hypotension). It is
important not to get out of bed as they might fall, provide bedside commode/ urinal if they want to use
rest room.
* Check the patient if he/she has an allergy to any medication.
* Advice not to swallow the medication or drink anything (because drinking water may dissolve and
lessen effectivity of medication).
* Test spray before giving the 1st dose (instruct the patient to open the mouth, curl up the tongue and
spray GTN under the tongue)
** important to give 1st dose to address chest pain then explain the rest after**
This medication can be given a maximum of 3 doses with a 5 minute interval each dose.
After 5 minutes, check obs (blood pressure) and pain score (1-10 highest).
Give the next dose if necessary.
If pain was relieved explain what happened.
That they had angina or chest pain, etc. (*do ur own research or read more about the medication)
Give health teaching.
(if this happens at home sit upright and DO NOT HESITATE TO USE THIS) and if unrelieved at 3rd those
call 911 or 112 and open the door.
If this happens at public place make to have emergency alert bracelet so people would know you have
this condition
And make sure to keep an extra bottle of GTN spray at work or in your bag.
Test spray before use and if haven't used in 5 days .check expiry date.
Then refer to the doctor for further management.
Then the assessor will give you a small paper to write your documentation and reflection.
Documentation Guide:
- Date & Time it happened.
- Patient complaint of chest pain
- Repositioned patient, assessed OPQRST and observation (vital signs taken especially the blood
pressure)
- GTN Spray given up to 3 doses (case to case basis)
- Observation taken before and after giving GTN with 5 minutes interval
- Pain score of 10/10 decreased (example: 3/10 and tolerable)
- Health teaching done
- Referred to Doctor or Medical Team
- Then write you Name, RGN Title then Date & Time
SUMMARY NOTES:
- REMEMBER TO ADDRESS PATIENT CONCERN AND PATIENT SAFETY FIRST.
- REPOSITION, ASSESS OPQRST, TAKE OBS , THEN IDENTIFY AGAIN (MRN)
- CHECK ALLERGY BEFORE GIVING MEDS.
- THANK THE ASSESSOR BEFORE GOING OUT IN THE STATION AND SMILE
-------
