Cardiac tamponade is a life-threatening condition characterized by fluid accumulation in the pericardial space, causing compression of the heart and compromised cardiac function. This nursing diagnosis focuses on identifying early signs, implementing immediate interventions, and preventing complications of cardiac tamponade.
Causes (Related to)
Cardiac tamponade can develop from various conditions and factors that affect pericardial integrity and function:
- Trauma-related causes:
- Chest trauma
- Cardiac surgery complications
- Invasive cardiac procedures
- Medical conditions:
- Pericarditis
- Malignancy
- Uremia
- Systemic lupus erythematosus
- Tuberculosis
- Other factors:
- Myocardial rupture
- Aortic dissection
- Anticoagulation therapy complications
- Radiation therapy
Signs and Symptoms (As evidenced by)
Subjective: (Patient reports)
- Chest pain or pressure
- Dyspnea
- Anxiety and restlessness
- Orthopnea
- Fatigue
- Dizziness or lightheadedness
- Weakness
Objective: (Nurse assesses)
- Beck’s triad:
- Hypotension
- Jugular venous distention
- Muffled heart sounds
- Tachycardia
- Paradoxical pulse
- Decreased cardiac output
- Cool, clammy skin
- Narrowed pulse pressure
- Pulsus paradoxus >10 mmHg
- Decreased urine output
Expected Outcomes
The following outcomes indicate successful management of cardiac tamponade:
- The patient will maintain stable hemodynamics
- The patient will demonstrate improved cardiac output
- The patient will report decreased dyspnea
- The patient will maintain adequate tissue perfusion
- The patient will demonstrate reduced anxiety
- The patient will avoid complications
- The patient will understand monitoring requirements
Nursing Assessment
Monitor Vital Signs
- Assess blood pressure, pulse, and respiratory rate
- Monitor for pulsus paradoxus
- Check the temperature for signs of infection
- Document cardiac rhythm
Evaluate Cardiovascular Status
- Assess heart sounds
- Monitor jugular venous distention
- Check peripheral pulses
- Evaluate capillary refill
- Monitor ECG changes
Assess Respiratory Status
- Monitor breathing pattern
- Check oxygen saturation
- Assess work of breathing
- Document the presence of orthopnea
- Evaluate lung sounds
Monitor Fluid Status
- Track intake and output
- Assess for edema
- Monitor daily weights
- Check skin turgor
- Evaluate mucous membranes
Check for Complications
- Monitor mental status
- Assess for signs of shock
- Watch for decreased cardiac output
- Check for activity intolerance
- Monitor pain levels
Nursing Care Plans
Nursing Care Plan 1: Decreased Cardiac Output
Nursing Diagnosis Statement:
Decreased Cardiac Output related to reduced ventricular filling due to pericardial fluid accumulation as evidenced by hypotension, tachycardia, and decreased urine output.
Related Factors:
- Pericardial fluid accumulation
- Impaired ventricular filling
- Reduced stroke volume
- Compromised cardiac contractility
Nursing Interventions and Rationales:
- Monitor vital signs q15min or as ordered
Rationale: Early detection of deterioration - Position patient in high Fowler’s position
Rationale: Optimizes venous return and reduces the workload on the heart - Administer oxygen as ordered
Rationale: Improves tissue oxygenation - Prepare for emergency pericardiocentesis
Rationale: Ensures readiness for life-saving intervention
Desired Outcomes:
- The patient will maintain BP within normal limits
- The patient will demonstrate improved cardiac output
- The patient will maintain adequate urine output
- The patient will report decreased symptoms
Nursing Care Plan 2: Impaired Gas Exchange
Nursing Diagnosis Statement:
Impaired Gas Exchange related to decreased pulmonary blood flow secondary to cardiac tamponade as evidenced by dyspnea and decreased oxygen saturation.
Related Factors:
- Reduced pulmonary perfusion
- Ventilation-perfusion mismatch
- Increased work of breathing
- Anxiety
Nursing Interventions and Rationales:
- Monitor oxygen saturation continuously
Rationale: Ensures adequate oxygenation - Assist with position changes
Rationale: Optimizes ventilation/perfusion matching - Administer supplemental oxygen
Rationale: Improves tissue oxygenation
Desired Outcomes:
- Patient will maintain O2 saturation >95%
- The patient will report decreased dyspnea
- The patient will demonstrate an improved breathing pattern
Nursing Care Plan 3: Anxiety
Nursing Diagnosis Statement:
Anxiety related to life-threatening condition and uncertain outcome as evidenced by expressed concerns, restlessness, and increased vital signs.
Related Factors:
- Threat to health status
- Fear of death
- Unfamiliarity with environment
- Pain and discomfort
Nursing Interventions and Rationales:
- Provide a calm, reassuring presence
Rationale: Reduces anxiety and promotes trust - Explain procedures and interventions
Rationale: Increases understanding and cooperation - Administer anti-anxiety medications as ordered
Rationale: Reduces psychological stress
Desired Outcomes:
- The patient will report decreased anxiety
- The patient will demonstrate improved coping
- The patient will verbalize understanding of the condition
Nursing Care Plan 4: Risk for Decreased Tissue Perfusion
Nursing Diagnosis Statement:
Risk for Decreased Tissue Perfusion related to compromised cardiac output secondary to cardiac tamponade.
Related Factors:
- Reduced cardiac output
- Hypotension
- Vasoconstriction
- Decreased oxygen delivery
Nursing Interventions and Rationales:
- Monitor peripheral pulses and capillary refill
Rationale: Indicates adequacy of tissue perfusion - Assess skin temperature and color
Rationale: Reflects peripheral circulation - Monitor urine output
Rationale: Indicates renal perfusion
Desired Outcomes:
- The patient will maintain adequate tissue perfusion
- The patient will demonstrate warm, pink extremities
- The patient will maintain urine output >30 mL/hr
Nursing Care Plan 5: Activity Intolerance
Nursing Diagnosis Statement:
Activity Intolerance related to imbalance between oxygen supply and demand as evidenced by dyspnea and fatigue with minimal exertion.
Related Factors:
- Decreased cardiac output
- Reduced oxygen delivery
- Bed rest deconditioning
- Weakness
Nursing Interventions and Rationales:
- Assess activity tolerance
Rationale: Prevents overexertion - Assist with ADLs
Rationale: Conserves energy - Plan activities with rest periods
Rationale: Prevents fatigue
Desired Outcomes:
- The patient will demonstrate improved activity tolerance.
- The patient will perform ADLs within energy limitations
- The patient will maintain stable vital signs during activity
References
- Brown, M. K., et al. (2023). Evidence-Based Nursing Interventions in Cardiac Tamponade: A Comprehensive Review. American Journal of Critical Care, 32(4), 278-292.
- Johnson, R. D., & Smith, P. A. (2023). Clinical Outcomes in Cardiac Tamponade: Updates in Nursing Care. Journal of Cardiovascular Nursing, 38(3), 145-158.
- Martinez, C. B., et al. (2023). Nursing Management of Cardiac Emergencies: Focus on Cardiac Tamponade. Heart & Lung: The Journal of Critical Care, 52(2), 89-102.
- Stashko E, Meer JM, Danitsch D. Cardiac Tamponade (Nursing) [Updated 2023 Aug 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK568727/
- Thompson, K. L., & Davis, R. M. (2023). Emergency Care of Cardiac Tamponade: A Guide for Critical Care Nurses. Dimensions of Critical Care Nursing, 42(1), 22-35.
- Williams, J. A., & Anderson, S. K. (2023). Cardiac Tamponade: Recognition and Management in Acute Care Settings. Journal of Emergency Nursing, 49(4), 412-425.
