About
Inflammation of the sac surrounding the heart, which may lead to fluid in the pericardial sac, constriction of the heart muscle movement, thickening of the pericardium, decreased ventricular filling.
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.
Complications
Constricted pericardium, heart failure, cardiac tamponade
Pericardial effusion, cardiac tamponade
Diagnosis
- Acute pain related to inflammation.
- Decreased cardiac output related to decreased ventricular filling.
- Risk for injury related to heart disease.
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
- Assess and monitor vitals, ECG, telemetry, CBC, pain levels frequently.
- Perform thorough cardiac and respiratory assessments frequently to monitor for changes.
- Monitor for acute shortness of breath, chest tightness, dizziness or pain which could indicate complication of cardiac tamponade. Notify physician immediately if symptoms present.
- Administer analgesics, anti-inflammatories, antibiotics as indicated by physician.
- Teach client to restrict activities during acute illness. May require bedrest.
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