Situation: A 34-year-old woman is admitted to the psychiatric unit with obsessive-compulsive disorder (OCD). She washes her hands for 3 to 4 hours a day because she fears contamination, and the skin of her hands is cracked and red. Her physical examination and electrocardiogram (ECG) on admission were normal. On her third day she suddenly grips the nurse's arm, trembling and breathing fast, and says her chest feels tight and she is going to die. Her pulse is 124/min. She has never had an episode like this before. The standing orders include a 12-lead electrocardiogram for new chest pain and an as-needed anxiolytic for severe anxiety. What should the nurse do FIRST?

The picture suggests a panic attack, but this is her first episode and includes chest tightness and tachycardia, so a medical cause must be excluded while the nurse stays with her and keeps her calm. Staying at her side while obtaining the ordered electrocardiogram meets both needs. Calling it anxiety before evaluation, medicating first, or teaching during panic is inappropriate.

The correct first action is to stay with her and obtain the 12-lead electrocardiogram. The clinical picture of trembling, tachypnea, chest tightness, a sense of impending doom, and tachycardia strongly suggests a panic attack. However, because this is her first episode and it includes chest symptoms with a pulse of 124/min, the nurse cannot safely label it as anxiety without first ruling out a medical cause.

Chest tightness and tachycardia are not exclusive to panic; they can also signal cardiac ischemia, arrhythmia, pulmonary embolism, or other acute medical conditions. The standing order for a 12-lead ECG for new chest pain exists precisely because the provider wants objective data before attributing the symptom to a psychiatric cause. The nurse’s presence during the ECG addresses both the safety need and the patient’s distress, which is consistent with the principle that a patient in acute distress should not be left alone.

The case described in the reference material reinforces this approach. The patient in that vignette repeatedly presented with tachycardia, dyspnea, chest pain, and fear of a heart attack, and each episode required negative work-ups—including electrocardiogram, cardiac enzymes, and Holter monitoring—before the diagnosis of panic disorder could be confirmed. Even when a pattern of panic is eventually established, the first presentation with chest symptoms must be evaluated medically. The repeated negative cardiac evaluations in that case do not mean the work-up was unnecessary; they mean the work-up was appropriately performed each time to exclude a cardiac event.

Option	Why it is not the first action
Guide slow breathing and tell her this is a panic attack	Calling the episode a panic attack before medical evaluation is premature and potentially dangerous if the cause is cardiac. Reassurance and breathing techniques can follow after the ECG is obtained.
Give the as-needed anxiolytic	Administering an anxiolytic first may mask or delay recognition of a cardiac or other medical event. The standing order is for severe anxiety, but the priority is to first rule out a new medical cause for chest pain.
Take her to a quiet room and teach muscle relaxation	Teaching a new skill during acute panic is ineffective because the patient cannot process new information while hyperaroused. Removing her from monitoring equipment before an ECG is also unsafe.

Watch out! A history of OCD with contamination fears does not protect the patient from a new cardiac event. The nurse must avoid diagnostic overshadowing—attributing all new physical symptoms to the known psychiatric diagnosis.

Key point! The nursing priority in a first episode of chest pain with tachycardia is to stay with the patient while obtaining the ordered diagnostic test. This simultaneously provides safety, reassurance, and objective data for the provider.