About
Collection of fluid in the pericardial sac.
Assess
Chest pain which may be in the neck area, scapula area or around the clavicle area, friction rub, fever, elevated wbc's, anemia, nonproductive cough, symptoms of heart failure, atrial arrhythmias, depressed PR segments or concave ST segment elevations. signs and symptoms of impaired tissue perfusion.
Complications
Cardiac tamponade, death
Diagnosis
- Decreased cardiac output related to impaired ventricular filling.
- Acute pain related to pressure on cardiac muscle.
- Risk for injury related to potential complications of fluid buildup.
- Impaired tissue perfusion related to inability for heart muscle to pump enough blood.
Goals
- The client will have a pain of less than 4 on a VAS 0-10 pain scale.
- The client will have a temperature within normal range.
- The client will have vital signs maintained within normal ranges.
- The client will have no pericardial friction rub upon auscultation.
- The client will have adequate oxygenation and tissue perfusion as indicated by pulse oximetry > 94%, adequate peripheral pulses, warm extremities.
Interventions
- Assess and monitor vitals, pulse-oximetry, telemetry, pain levels.
- Maintain client on bedrest to decrease metabolic needs.
- Prepare client for pericardiocentesis if symptoms worsen or do not improve.
- Monitor for signs of cardiac tamponade ( shortness of breath, chest pain, dizziness, decrease in systolic blood pressure, tachycardia, erratic dissimilar QRS complexes).
- Teach client to report chest pain, sudden shortness of breath, dizziness or any other acute sudden changes in condition.
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