Last updated on January 28th, 2024 at 08:13 am
Cardiac Tamponade Nursing Care Plans Diagnosis and Interventions
Cardiac Tamponade NCLEX Review and Nursing Care Plans
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.
Cardiac Tamponade Nursing Diagnosis
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.
|Cardiac Tamponade Nursing Interventions
|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.
Cardiac Tamponade 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.
|Cardiac Tamponade Nursing Interventions
|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.
Cardiac Tamponade 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.
|Cardiac Tamponade Nursing Interventions
|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.
Cardiac Tamponade Nursing Care Plan 4
Nursing Diagnosis: Ineffective Tissue Perfusion related to the reduction of blood flow secondary to cardiac tamponade as evidenced by cyanosis, dysrhythmias, dyspnea, and abnormal arterial blood gases.
- The patient will show increased perfusion and return to its normal range.
- The patient will maintain his/her vital signs and arterial blood gases at normal levels.
|Cardiac Tamponade Nursing Interventions
|1. Check for the patient’s heart rate, and blood pressure by intra-arterial monitoring as directed by the physician.
|It is important to check for the blood pressure and heart rate because sinus tachycardia and increased blood pressure may be seen to maintain sufficient cardiac output. Blood pressure may drop as the. condition deteriorates. Cardiac tamponade happens because of the extra fluids build up in the space around the heart that may cause changes in the patient’s heart rate and blood pressure. The fluid in the heart causes pressure and will make the heart difficult to pump.
|2. Check for the patient’s level of consciousness and check for any signs of cerebral hypoxia.
|Cerebral hypoxia’s early signs are restlessness and anxiety while confusion and loss of consciousness appear in the later stage of cerebral hypoxia. Cerebral hypoxia happens when the oxygen in the brain is not sufficient.
|3. Check for the patient’s capillary refill by pressing the nail bed of the patient until turns white for 3 seconds or less and record the time when the nail beds return to their normal color.
|A capillary refill test is done to assess the flow of blood through the peripheral tissues. A capillary refill test is also done to check for signs of dehydration.
|4. Check the arterial blood gases and oxygen saturation level of the patient from time to time.
|A pulse oximeter is used to measure the saturation of oxygen carried in the patient’s red blood cells. The normal level of oxygen in the blood is 90% or higher. When the oxygen in the blood is decreased it may indicate hypoxemia which causes the body not to work properly and may affect the person’s organs system. Arterial blood gases are used to identify oxygen, carbon dioxide, and the pH balance in the patient’s blood.
|5. Check for the color, temperature, and the extremities’ sensation.
|Color, temperature, and sensation of the extremities may be affected and may indicate inadequate blockage of the extremities perfusion.
|6. Arrange for oxygen therapy if indicated.
|Administering oxygen to the patient will help to increase the oxygen carried by the hemoglobin to the blood. Oxygen is needed by all tissues that will support metabolism.
|7. Provide intravenous fluids as ordered by the physician.
|It is important to maintain adequate fluid to boost the cardiac output needed for tissue perfusion.
|8. Check for the patient’s hemoglobin level.
|Oxygen saturation may be decreased and will cause a decrease in hemoglobin level. If the hemoglobin is decreased the tissues and the organs in the body may not get enough oxygen. Normal hemoglobin levels differ for men and women. For men, the normal range is between 14gm/dl to 17.5 gm/dl. For women, the normal level is 12.3 gm/dl to 15.3 gm/dl.
|9. Monitor for the patient’s urine output from time to time
|Fluid balance may be affected if there is a presence of decreased perfusion. Checking the patient’s urine output may decrease the risk of complications.
|10. Advise the patient to limit activity and maintain bed rest.
|Bed rest and limiting the patient’s activity will minimize the oxygen demand. This will also help to promote the patient’s rest.
|11. identify the possible factors that may precipitate that may cause compromised tissue perfusion.
|Precipitating factors such as medications, positioning, pathology, and medical equipment may affect tissue perfusion. These precipitating factors may cause complications if not monitored closely.
Cardiac Tamponade Nursing Care Plan 5
Nursing Diagnosis: Excess Fluid Volume related to decreasing plasma protein, increased sodium, and presence of water retention secondary to cardiac tamponade as evidenced by the change in mental status, edema, dyspnea, weight gain, and shortness of breath.
- The patient will maintain appropriate fluid volume.
- The patient will sustain normal vital signs.
- The patient will sustain normal weight and be free from edema.
|Cardiac Tamponade Nursing Interventions
|1. Check for the urine color, amount, and urine output as well as the vital signs of the patient.
|Changes in the urine output may happen due to decreased renal perfusion. Vital signs may also be affected and may cause low blood pressure and weak pulse due to the reduced volume of blood in the heart. Decreased cardiac output and hypotension may cause decreased renal failure.
|2. Monitor the lungs of the patient through auscultation and assess for the presence of abnormal breath sounds such as crackles and wheezes.
|Abnormal breath sounds are one of the possible manifestations of cardiac tamponade and may indicate pulmonary congestion. Wheezing is a shrill whistle-like sound that can be heard when the airway is partially blocked. Wheezes can also be a sign of heart failure and other diseases. Wheezes may go on their own but it could also be a sign of a serious condition or complication. Crackles is an abnormal breath sound that produces crackling noises in the lungs. Crackles may be caused by collapsed alveoli by the fluid or by “popping open” of small airways. Crackles may be heard in the lungs of the patient with heart problems and other conditions.
|3. Check the patient’s output and intake correctly.
|Decreased renal perfusion and impaired fluid volume may happen due to decreased cardiac output that will cause retention of water and sodium and causes oliguria. Decreased renal perfusion happens because of the decrease in blood pressure and decreased fluids through the kidney which may cause impaired fluid volume as well.
|4. Check the patient for the presence of edema.
|Edema is caused by the excess fluid trapped in the person’s body which causes swelling. Edema usually happens in the patient’s ankle, knee, and legs and can also affect the face and hands. For patients with edema, the nurse may notice the skin in the swollen area is shiny and stretched.
|5. Check the veins in the neck for the presence of distention.
|Distended jugular veins may indicate excess fluids. Jugular vein distention is when the vein in the neck bulges that can be a sign of cardiac problems and other serious conditions.
|6. Check for the patient’s level of electrolytes, especially the patient’s potassium level.
|Potassium levels may be affected causing hypokalemia. Hypokalemia is caused by a decreased level of potassium. Potassium is important to the person’s body because it carries electrical signals to the cells in the person’s body. Potassium is important for proper body functioning especially in the heart muscles. The normal potassium level is 3.6 to 5.2 mmol/L.
|7. Check the patient’s chest x-ray for any abnormal findings.
|Checking the chest x-ray of the patient will help to evaluate any signs of development and worsening of a lung condition.
|8. Place the patient in semi fowler’s position or a comfortable position.
|Positioning the patient in a semi Fowler’s position will increase renal filtration and reduce ADH production thus promoting diuresis.
|9. Change the patient’s position frequently and with an interval of at least every 2 hours as tolerated.
|Changing the patient’s position frequently will decrease the risk for pressure ulcers and will help to improve breathing and mobilization of secretions.
|10. Educate and instruct the patient to follow a low sodium diet.
|Electrolyte retention and fluid retention may be reduced when doing a low sodium diet. A low sodium diet will help avoid extra fluids around the heart and the lungs. Excess fluids in the body will make the heart work harder and may cause an increase in blood pressure.
|11. Give diuretics as indicated and as ordered by the physician.
|Administering diuretics will help decrease the volume of plasma and peripheral edema. Diuretics help the kidneys to release sodium into the patient’s urine which will also cause a decrease in blood pressure. Diuretics are also used to treat pulmonary edema.
Cardiac Tamponade Nursing Care Plan 6
Nursing Diagnosis: Anxiety related to change in health status, fear of death, and unfamiliar environment secondary to cardiac tamponade as evidenced by agitation, uncooperative behavior, and sympathetic stimulation.
- The patient will demonstrate utilization of coping mechanisms to reduce anxiety.
- The patient will cooperate with interventions to avoid and reduce anxiety.
|Cardiac Tamponade Nursing Interventions
|1. Ask the patient about the previous methods of coping used.
|People differ in the way how they handle and decrease anxiety. The patient’s coping pattern will help the interventions to be more effective. Coping strategies help to regulate emotions, and behaviors and will help manage stressful situations. Whether the patient is feeling lonely, nervous, sad, or angry, coping strategies will help the patient to deal with the feelings healthily. The level of anxiety may be categorized into four categories: mild anxiety, moderate anxiety, severe anxiety, and panic level anxiety.
|2. Check the patient’s anxiety level and presence of shock.
|Experiencing anxiety and shock is common to the patient and the patient’s family and significant others. Anxiety can affect the patient’s daily functioning and how the patient will respond to care and situation.
|3. Explain the procedures appropriately and keep the explanations basic so that the patient will easily understand.
|Giving information to the patient before the procedures will help to reduce anxiety. Patients that are experiencing anxiety may have difficulty in understanding. The burse should explain in a simple and clear instruction.
|4. Advise the patient to express his or her feelings and emotions about the procedure and the condition.
|Asking the patient about anxious feelings and situations that produces anxiety can help the patient to adapt to the situation in a life-threatening manner. Emotions can be expressed through words or by non-verbal communication including the patient’s body language and body expressions.
|5. Acknowledge and be aware of the patient’s feelings and anxiety.
|The nurse should acknowledge the feelings of the patient to gain trust which will help to validate the patient’s feelings and will communicate acceptance of the patient’s feelings.
|6. Reduce stimuli that are not necessary for maintaining a quiet environment. If the source of anxiety is the medical equipment, consider providing the client with a sedative.
|Noise, excessive conversation, and equipment around the client may increase anxiety. Maintaining a low stimulus environment will help decrease anxiety
|7. Reassuring the patient and the significant others of monitoring the patient continuously will guarantee prompt intervention and confidence should always be maintained while interacting with the patient and the significant others.
|The anxiety of the nurse or the caregivers may easily be perceived by the patient. The patient’s feeling of stability will be increased if the nurse will provide a calm and non-threatening environment. The presence of the family and significant others is important for the patient. The patient will feel less threatened if the family and the significant others are around.
|8. Educate the patient and the significant others on the ways to cope and treat anxiety.
|The nurse should discuss ways how to decrease anxiety such as encouraging positive thinking, stress management, and relaxation techniques. Encourage the family members and significant others to support the patient and empathize with the patient’s condition.
|9. Maintain the patient’s safety at all times, especially during an anxiety attack.
|Ensuring safety during anxiety is important to decrease and prevent risks that may harm the patients. Patient safety is a priority to deliver quality and effective health services.
|10. Encourage the patient to be part of setting goals and planning of care.
|If the patient is actively participating in the development of goals and plans, the interventions will be more effective. Goal setting is important to create realistic and specific goals.
|11. Provide pharmacological remedies as needed and as prescribed by the attending physician.
|Antianxiety drugs may be given to the patient for a short period to improve the patient’s condition.
|12. Encourage the patient to have ample sleep and rest.
|Anxiety may affect the ability of the patient to fall asleep. Lack of sleep can increase the risk of having insomnia and anxiety problems.
More Cardiac Tamponade Nursing Diagnosis
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. (2022). 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. (2020). 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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