About
Removal of fluid surrounding the heart 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. Color and characteristics of aspirated contents, injection site.
Complications
- Infection, perforation of the heart, pneumothorax
Diagnosis
- Risk for infection related to invasive procedure.
- Risk for injury related to procedure and complications.
- Knowledge deficit related to procedure.
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.
Interventions
- Teach client what to expect prior to, during, and after procedure.
- Assess vitals, lungs sounds, heart rate and rhythm, pulse-oximetry.
- Monitor insertion site for infection, bleeding, bruising.
- Teach client signs and symptoms to report immediately to health care provider.
- Maintain bedrest if acute infection present.
- Monitor for acute shortness of breath, chest tightness, dizziness or pain which could indicate complication of cardiac tamponade. Notify physician immediately if symptoms present.
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