Cardiac Tamponade NCLEX Review Care Plans
Nursing Study Guide for Cardiac Tamponade
Cardiac tamponade is a medical condition wherein there is an increase of fluid in the pericardial space, thereby causing pressure to the heart.
The heart is the primary organ responsible for the circulation of the blood all throughout the body.
Enveloping the heart is an elastic membrane called the pericardium, wherein in between lays the pericardial space containing the pericardial fluid. The pericardium not only acts as the protective barrier of the heart, but its pericardial fluid lubricates the structures and limits friction during heart contraction.
Signs and Symptoms of Cardiac Tamponade
The classic clinical manifestations of cardiac tamponade are as follows:
- Elevated jugular vein pressure
- Pulsus Paradoxus – also known as paradoxical pulse; abnormal drop of more than 10 mmHg of the patients’ blood pressure during inspiration
- Pressure in the chest – which causes increasing chest pain during deep breathing, palpitations
- Decreased urine output
- Dysphoria – feelings of anxiety or restlessness
Causes and Risk Factors of Cardiac Tamponade
In cardiac tamponade, excess fluid or blood collects in the pericardium. This excess inhibits the heart from fully contracting, thereby causing increased in cardiac pressure.
The increase in cardiac pressure and the restrictions brought about by the pooling of excess fluid, compromises the circulation of blood throughout the body.
The associated risk factors of cardiac tamponade are listed below:
- Dissecting aortic aneurysm
- End-stage lung cancer
- Heart attack
- Heart surgery
- Inflammation of the heart (Pericarditis); maybe bacterial or viral in origin
- Trauma or wound in the heart
Other causative factors are:
- Heart tumors
- Hypoactive thyroid gland
- Kidney failure
- Placement of central access lines
- Radiation therapy to the chest
- Recent invasive cardiac procedures and/or surgery
- Systemic lupus erythematosus
- Dermatomyositis – a rare inflammatory autoimmune disease of the skin and muscles
- Heart failure
Complications of Cardiac Tamponade
Cardiac tamponade is a medical emergency requiring prompt management. Prognosis will depend on its early diagnosis, management of the condition, and treatment of the underlying cause.
If left untreated, the following complications may occur and are listed below:
- Heart failure
- Pulmonary edema
Diagnosis of Cardiac Tamponade
Diagnosing cardiac tamponade entails the following workup and procedures:
- Imaging studies
- Chest radiography or chest Xray – may show a water bottle-shaped heart, calcifications or presence of chest trauma. A sign of a bowed catheter post insertion of central venous catheter, maybe indicative of tamponade.
- CT scan – 46% of patients showed compression of the coronary sinus after CT scans of the chest indicating early marker for cardiac tamponade.
- Echocardiography – a specialized procedure enabling for the accurate visualizations of the heart and its surrounding structures. This procedure will easily reveal any disturbances or malfunction of the heart and can approximate the amount of fluid in cardiac tamponade.
- Laboratory studies
- Creatine kinase and isoenzymes – elevated levels is indicative of cardiac compromise and trauma
- Renal profile and Complete blood count – useful in determining renal function and infective causes of pericarditis that may contribute to cardiac tamponade
- Coagulation panel – Prothrombin time (Protime) and activated partial thromboplastin time (APTT) are useful to assess bleeding risks before surgical intervention is done
- Antinuclear antibody assay, erythrocyte sedimentation rate and rheumatoid factor – Non-specific test that if elevated maybe indicative of connective tissue disease, which likewise is a risk factor for cardiac tamponade.
- HIV testing – 24% of all pericardial effusions are associated with HIV infections
- Electrocardiography – In a 12 lead ECG, the following can be observed that maybe suggestive for cardiac tamponade:
- sinus tachycardia
- low voltage QRS complex
- Electrical alternans – alternating QRS complex, usually in a 2:1 ratio
- PR segment depression
- Swan-Ganz catheterization – or pulmonary artery catheterization will show a near equalization (within 5 mmHg) of the right atrial, right ventricular diastolic, pulmonary arterial diastolic and pulmonary capillary wedge pressure (reflecting left atrial pressure) occurs, in tamponade.
Treatment for Cardiac Tamponade
Management of cardiac tamponade involves primarily surgical and supportive care management with limited medication therapy.
Enumerated below are the interventions done for tamponade:
- Supportive care. This is preferably in the Intensive Care Unit (ICU) for monitoring.
- Oxygen supplementation
- Use of volume expanders such as blood, plasma, dextran, or isotonic sodium chloride to maintain adequate intravascular pressure and volume
- Complete bed rest with the elevation of the lower extremities – aides to increase venous return
- Positive pressure ventilation should be avoided because it decreases venous blood return and may worsen signs and symptoms of tamponade.
- Surgical intervention
- Pericardiocentesis and pericardiotomy – removal of excess pericardial fluid, with or without imagery guidance and can be done through 3 methods:
- Emergency subxiphoid percutaneous drainage – involves insertion of a 16 to 18 gauge needle at an angle of 30-45 degrees to the skin near the left xiphocostal angle, to the direction of the left shoulder.
- Echocardiographically-guided pericardiocentesis – usually done in the cardiac catheterization laboratory
- Percutaneous balloon pericardiotomy – approach same as the guided pericardiocentesis, with the balloon utilized to create a pericardial window.
- For recurrent tamponade, the following may be done:
- Sclerosing the pericardium – introduction of either corticosteroid,, tetracycline or antineoplastic drugs in the pericardial space
- Pericardio-peritoneal shunt
- Pericardiectomy – surgical resection of the pericardium
- Medical management using inotropic agents. Medical treatment involves the use of synthetic catecholamines and direct inotropic agent that affects beta-1 receptors in the heart thereby increasing stroke volume and cardiac output.
Nursing Care Plans for Cardiac Tamponade
Nursing Care Plan 1
Nursing Diagnosis: Decreased Cardiac Output related to a reduction in ventricular filling secondary to elevated intrapericardial pressure as evidenced by irregular heartbeat, pulsus paradoxus, blood pressure of 89/58, restlessness, dyspnea upon exertion, and fatigue.
Desired outcome: The patient will be able to maintain adequate cardiac output.
|Assess the patient’s vital signs and characteristics of blood pressure at least every 15 minutes during the acute phase. Assess breath sounds via auscultation. Observe for signs of decreasing peripheral tissue perfusion such as slow capillary refill, facial pallor, cyanosis, and cool, clammy skin.||To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment. The presence of signs of decreasing peripheral tissue perfusion indicate deterioration of the patient’s status which require immediate referral to the physician.|
|Monitor ECG continuously for any signs of dysrhythmia.||To monitor any worsening of the quality of cardiac output.|
|Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician.||To increase the oxygen level and achieve an SpO2 value within target range.|
|Administer medications as prescribed.||Medical treatment involves the use of synthetic catecholamines and direct inotropic agent that affects beta-1 receptors in the heart thereby increasing stroke volume and cardiac output.|
|Prepare the patient for surgery as indicated.||Pericardiocentesis and pericardiotomy can be done to facilitate the removal of excess pericardial fluid. Recurrent cardiac tamponade may be treated through sclerosing the pericardium, pericardio-peritoneal shunt, or pericardiectomy.|
Nursing Care Plan 2
Nursing Diagnosis: Acute Pain related to increased intrapericardial pressure as evidenced by pain score of 10 out of 10, verbalization of pressure-like chest pain, guarding sign on the chest, blood pressure level of 180/90, respiratory rate of 29 bpm, and restlessness
Desired Outcome: The patient will demonstrate relief of pain as evidenced by a pain score of 0 out of 10, stable vital signs, and absence of restlessness.
|Administer prescribed medications that alleviate the symptoms of chest pain.||Aspirin may be given to reduce the ability of the blood to clot, so that the blood flows easier through the narrowed arteries. Nitrates may be given to relax the blood vessels. Other medications that help treat chest pain include anti-cholesterol drugs (e.g. statins), beta blockers, calcium channel blockers, and Ranolazine.|
|Assess the patient’s vital signs and characteristics of pain at least 30 minutes after administration of medication.||To monitor effectiveness of medical treatment for the relief of chest pain. The time of monitoring of vital signs may depend on the peak time of the drug administered.|
|Elevate the head of the bed if the patient is short of breath. Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician.||To increase the oxygen level and achieve an SpO2 value within the target range.|
|Place the patient in complete bed rest during chest pain attacks. Educate patient on stress management, deep breathing exercises, and relaxation techniques.||Stress causes a persistent increase in cortisol levels, which has been linked to people with cardiac issues. The effects of stress are likely to increase myocardial workload.|
Nursing Care Plan 3
Nursing Diagnosis: Fatigue related to decreased oxygenation of the blood as evidenced by overwhelming lack of energy, verbalization of tiredness, generalized weakness, and shortness of breath upon exertion
Desired Outcome: The patient will establish adequate energy levels and will demonstrate active participation in necessary and desired activities.
|Ask the patient to rate fatigue level (mild, moderate, or severe fatigue). Assess the patient’s activities of daily living, as well as actual and perceived limitations to physical activity. Ask for any form of exercise that he/she used to do or wants to try.||To create a baseline of activity levels, degree of fatigability, and mental status related to fatigue and activity intolerance.|
|Encourage progressive activity through self-care and exercise as tolerated. Explain the need to reduce sedentary activities such as watching television and using social media in long periods. Alternate periods of physical activity with rest and sleep.||To gradually increase the patient’s tolerance to physical activity. Sedentary lifestyle is a risk factor to develop heart disease.|
|Encourage the patient to follow a low cholesterol, high caloric diet. Refer to the dietitian as needed.||To increase energy levels while promoting a lower risk for chest pain and heart disease.|
|Teach deep breathing exercises and relaxation techniques. Provide adequate ventilation in the room.||To allow the patient to relax while at rest. To allow enough oxygenation in the room.|
|Refer the patient to physiotherapy / occupational therapy team as required.||To provide a more specialized care for the patient in terms of helping him/her build confidence in increasing daily physical activity.|
Other possible nursing diagnoses:
- Impaired Urinary Elimination / Decreased Urinary Output
- Risk for Shock
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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