Pericardial Effusion Nursing Care Plans Diagnosis and Interventions
Pericardial Effusion NCLEX Review and Nursing Care Plans
Pericardial effusion is a medical condition characterized by the build-up of fluid in the pericardium, a sac-like structure covering the heart consisting of two layers.
The pericardium normally contains a small amount of fluid; however, excess collection of fluid can cause extra strain to the heart muscles affecting its function.
Pericardial effusion is typically a symptom of other diseases such as infection, heart diseases, kidney failure, and chest trauma. The build-up of fluid can range from just a few millilitres up to about 2 litres of fluid.
A small amount of pericardial fluid build-up is often undiagnosed; however, significant build-up of fluid can lead to serious compromise in the function of the heart.
Signs and Symptoms of Pericardial Effusion
The signs and symptoms of pericardial effusion depend on the rate of fluid build-up and the amount of fluid present.
It can have an acute onset, therefore signs and symptoms may appear fast and quick especially when the amount of fluid is significantly high.
On the other hand, chronic pericardial effusion may have a slow manifestation of its signs and symptoms.
- Pericardial friction rub – also known as pericardial rub; a high-pitched heart sound often heard during expiration.
- Chest pain which is often relieved by sitting up and leaning forward and is commonly intensified by lying on the back
- Light-headedness; and in other cases, syncope
- Dyspnea or shortness of breath
- Hoarseness of voice
- Anxiety and confusion
- Edema – swelling in the legs or abdomen
- Muffled heart sounds
- Jugular vein distention
Causes of Pericardial Effusion
Some cases of pericardial effusion are idiopathic or have an unknown cause.
In other cases, pericardial effusion occurs because of an illness or a disease, such as:
- Infectious pericarditis – infection of the pericardium is often the cause of pericardial effusion. The inflammation leads to the collection of fluid in the pericardial sac.
- Acute myocardial infarction
- Acute kidney disease or chronic kidney disease
- Malignancy or as a complication of treatment from chemotherapy and radiotherapy
- Benign tumors
- Familial Mediterranean fever
- Whipple’s disease
- Ruptured aortic aneurysm with leakage
- Severe chronic anemia
- Local effusion secondary to recent cardiac surgery
- Autoimmune diseases causing systemic inflammation such as systemic lupus erythematosus, rheumatoid arthritis, ankylosing spondylitis, rheumatic fever, and scleroderma.
- Drug-induced pericardial effusion
Complications of Pericardial Effusion
- Cardiac Tamponade. This is a serious medical emergency requiring immediate medical attention. It is a condition where the build-up of pericardial fluid leads to an increase in intra-pericardial pressure restricting the heart leading to reduced cardiac output.
- Chronic Pericardial Effusion. Pericardial effusions can last longer than 6 months, causing significant disruption of a patient’s quality of life.
Diagnosis of Pericardial Effusion
- Medical history and Physical Examination – history and physical assessment will help identify the presence of any signs and symptoms and diagnose any condition that may lead to pericardial effusion. Auscultation of the heart sounds is particularly helpful to note the presence of pericardial friction rub.
- Full blood count – shows raised WBC count, or may show any sign of an underlying disease which can cause pericardial effusion.
- Renal function tests and electrolytes – blood test to determine uremia which is common in pericardial effusion
- Thyroid function tests – hypothyroidism can lead to pericardial effusion
- Cardiac enzymes – troponin level may be elevated in pericarditis, a condition which may lead to pericardial effusion.
- Auto-antibodies – examples are rheumatoid factor and antinuclear antibody, which can help identify possible autoimmune causes of pericardial effusion.
- Blood cultures – these are done when infection is suspected
- Elevated carcinoembryonic antigen (CEA) – CEA levels are sometimes measured to identify malignant effusion
- Echocardiogram – involves the use of a sound-emitting device to take pictures of the heart. It can be done in two different ways:
- Transthoracic echocardiography – the transducer is placed over the chest to take images of the heart.
- Transesophageal echocardiography – the transducer is placed on a tiny tube which is then inserted down into the digestive tract to make it closer to the heart and take even more detailed images.
- Electrocardiogram – involves the use of electrodes attached on the chest to trace electric signals of the heart. In pericardial effusion, raised ST segments, diminished QRS and T-wave, PR segment depression and ST-T changes may be noted.
- Pericardial effusion aspiration analysis – a sample of the pericardial fluid is analysed for protein level, cell count, and is cultured for possible bacterial / viral growth.
- MRI / CT scan – imaging tests may be performed to help diagnose pericardial effusion. Both imaging techniques can detect local pericardial effusion and thickening although MRI is more sensitive and can detect fluid build-up of as little as 30mL.
- Pericardial biopsy – this procedure is rarely done unless malignant pericardial effusion is suspected.
Treatment of Pericardial Effusion
The treatment for pericardial effusion depends on the amount and cause of the disease together with the likelihood of developing cardiac tamponade.
- Medications. Anti-inflammatory drugs are often used to treat pericardial effusion if the risk of developing cardiac tamponade is low. Antibiotics are given if the pericardial effusion is caused by a bacterial infection. Diuretics are given if the condition is due to heart failure.
- Medical procedures and surgery. In some cases, the fluid accumulation will need to be drained using a more invasive procedure, which may be one of the following:
- Pericardiocentesis – this procedure involves the aspiration of pericardial fluid using a small needle guided by echocardiography or fluoroscopy.
- Open heart surgery –may be required to drain the fluid accumulation. This is mostly done in individuals who developed pericardial effusion following a heart surgery.
- Balloon pericardiotomy – a rarely performed procedure where a balloon is inserted between the layers of the pericardium to inflate and stretch the two.
- Pericardiectomy – surgical removal of the pericardium and is performed in individuals not responding to other treatments.
Nursing Diagnosis for Pericardial Effusion
Pericardial Effusion Nursing Care Plan 1
Decreased cardiac output secondary to pericardial effusion as evidenced by palpitations, blood pressure level of 85/50, pericardial friction rub, bilateral leg edema, fatigue and inability to do ADLs as normal
Desired outcome: The patient will be able to maintain adequate cardiac output.
|Nursing Interventions for Pericardial Effusion||Rationales|
|Assess the patient’s vital signs and characteristics of heart beat at least every 4 hours. Assess heart 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. Pericardial friction rub is an important heart sound that can help in diagnosing pericardial effusion. The presence of signs of decreasing peripheral tissue perfusion indicate deterioration of the patient’s status which require immediate referral to the physician.|
|Administer medications as prescribed.||Anti-inflammatory drugs are often used to treat pericardial effusion if the risk of developing cardiac tamponade is low.|
Antibiotics are given if the pericardial effusion is caused by a bacterial infection.
Diuretics are given if the condition is due to heart failure.
|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.|
|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. Chronic stress may also cause an increase in adrenaline levels, which tend to increase the heart rate, respiratory rate, and blood sugar levels. Reducing stress is also an important aspect of dealing with fatigue.|
|Prepare the patient for surgical intervention.||The surgeon may indicate the following surgeries as needed for pericardial effusion: |
Pericardiocentesis – a procedure that involves the insertion of a needle into the pericardial sac to aspirate the fluid build-up.
Open heart surgery –may be required to drain the fluid accumulation. This is mostly done in individuals who developed pericardial effusion following a heart surgery.
Balloon pericardiotomy – a rarely performed procedure where a balloon is inserted between the layers of the pericardium to inflate and stretch the two.
Pericardiectomy – surgical removal of the pericardium and is performed in individuals not responding to other treatments.
Pericardial Effusion Nursing Care Plan 2
Nursing Diagnosis: Acute Pain related to inflammatory process of pericardial effusion secondary to bacterial pericarditis, as evidenced by chest pain score of 10 out of 10 and is often relieved by sitting up and leaning forward, chest pain ism intensified by lying on the back, guarding sign, restlessness, and shortness of breath
Desired Outcome: The patient will have a pain score of 0 out of 10.
|Nursing Interventions for Pericardial Effusion||Rationales|
|Assess the patient’s vital signs. Ask the patient to rate the pain from 0 to 10, and describe the pain he/she is experiencing.||To create a baseline set of observations for the patient. The 10-point pain scale is a globally recognized pain rating tool that is both accurate and effective.|
|Administer analgesics/ pain medications as prescribed. Administer antibiotics as prescribed.||To provide pain relief to the patient. To treat the underlying infection.|
|Ask the patient to re-rate his/her acute pain 30 minutes to an hour after administering the analgesic.||To assess the effectiveness of treatment.|
|Provide more analgesics at recommended/prescribed intervals.||To promote pain relief and patient comfort without the risk of overdose.|
|Elevate the head of the bed and encourage the patient to sit in semi Fowler’s position. Advise the patient to lean forward onto a movable table and pillow in front and avoid lying on his/her back. Encourage pursed lip breathing and deep breathing exercises.||To relieve shortness of breath and help in lung expansion. To promote optimal patient comfort and reduce pain, anxiety, and restlessness.|
Pericardial Effusion Nursing Care Plan 3
Nursing Diagnosis: Activity intolerance related to acute chest pain as evidenced by pain score of 8 to 10 out of 10, fatigue, disinterest in ADLs due to pain, verbalization of tiredness and generalized weakness
Desired Outcome: The patient will demonstration active participation in necessary and desired activities and demonstrate increase in activity levels.
|Nursing Interventions for Pericardial Effusion||Rationales|
|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 and mental status related to acute pain, 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 60-90 minutes of undisturbed rest.||To gradually increase the patient’s tolerance to physical activity. To prevent triggering of acute pain by allowing the patient to pace activity versus rest.|
|Administer analgesics as prescribed prior to exercise/ physical activity. Teach deep breathing exercises and relaxation techniques. Provide adequate ventilation in the room.||To provide pain relief before an exercise session. To allow the patient to relax while at rest and to facilitate effective stress management. 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.|
Pericardial Effusion Nursing Care Plan 4
Nursing Diagnosis: Acute Pain related to the inflammation of the pericardium secondary to pericardial effusion as manifested by shortness of breath, the difficulty of breathing, and discomfort with breathing while the person is lying down and has a pain scale of 10 out of 10.
- The patent will verbalize pain scale was decreased to 0 out of 10.
- The patients will be kept comfortable during the interventions.
- The patient will verbalize his/her response to pain management and interventions.
- The patient vital signs will remain at their normal range.
|Nursing Interventions for Pericardial Effusion||Rationale|
|1. The patient will be assessed for his/her present condition; assess the patient’s vital signs, pain scale, the severity of pain, location of pain, characteristics, frequency, and duration. Include the assessment of the patient’s allergy to medications such as non-steroidal anti-inflammatory drugs (NSAIDs) which can be used as a pain reliever if prescribed.||To assess the patient’s baseline status and to properly recognize the interventions to be given to the patient to help improve the patient’s condition. And to provide proper medications to the patient.|
|2. Administer medications that will help to relieve pain as prescribed by the physician. Watch out for signs of allergies. Watch out for any signs and symptoms of drug reaction.||To provide comfort to the patient and lessen the pain that the patient is experiencing.|
|3. Assess the patient after 30 minutes to 1 hour after the medication administration, and closely monitor the patient’s reaction to pain medication.||To assess the efficacy of the pain medication that was given to the patient as prescribed by the physician. It is important to evaluate the patient’s reaction to pain medications because the pain medications are absorbed differently by every individual.|
|4. Give additional pain medication to the patient if the pain scale still does not decrease as prescribed by the physician, taking note of the proper intervals and dosage.||To provide relief and sustain the comfort of the patient. Giving medications at intervals is very important to give the proper amount of medications that the body needs.|
|5. Provide physical stimulation to the patient that may help to temporarily alleviate the pain such as massage, hot and cold application, and acupressure.||Physical stimulations can temporarily alleviate the pain because it works by distracting the patients away from the painful sensations and physical stimulation aids relaxation and decreases muscle tension.|
|6. Instruct the patient to do deep breathing exercises and elevate the head of the bed and reposition the patient to semi-fowler’s position as tolerated by the patient.||Preventing shortness of breath and providing comfort to the patient will also help to relieve pain and reduce the anxiety that is very common to a patient who is experiencing acute pain. Deep breathing exercises promote stability and decrease anxiety.|
|7. Reassess the condition of the patient, the vital signs, and the pain scale of the patient after the interventions that were given and prescribed by the physician. Assess the patient’s response to pain management and interventions.||To evaluate the effectiveness of the medication and interventions that were given to the patient to be able to decide if the patient still needs additional intervention as prescribed by the physician.|
|8. Refer the patient to the physician to assess if there is development after the medications and interventions that have been done to the patient.||To provide further interventions and evaluation that can help in the improvement of the patient’s condition.|
|9. Encourage the patient’s significant others and relatives to constantly monitor the patient’s pain and provide emotional support for the patient.||Patients may become anxious and may cause stress about their condition. Emotional and social support from the significant others is very important for the patients’ recovery.|
Pericardial Effusion Nursing Care Plan 5
Ineffective Breathing Pattern
Nursing Diagnosis: Ineffective Breathing Pattern related to altered oxygen supply secondary to pericardial effusion as manifested by the difficulty of breathing, body weakness, restlessness, using of accessory muscles, and increased respiratory rate.
- The patient’s breathing pattern will return to its normal rate.
- The patient will report changes of difficulty in breathing.
- The patient’s ABG level will return to its normal level.
- The patient will verbalize the knowledge of deep breathing exercises and relaxation techniques.
|Nursing Interventions for Pericardial Effusion||Rationale|
|1. Check the vital signs of the patient, especially the patient’s respiratory rate, breathing pattern, depth, and characteristics.||To obtain baseline data and for early detection and diagnosis of any respiratory complications. Vital signs help in revealing the body’s functions.|
|2. Check the arterial blood gases (ABG) levels of the patient.||To measure the oxygen level, carbon dioxide, and the acid-base balance from the blood of the patient to prevent further complications.|
|3. Auscultate the patients’ breath sounds and monitor the characteristics of the patient’s breathing.||To identify decreased and abnormal breath sounds which include; rales, wheezes, rhonchi, stridor, expiratory grant, and bronchospasm.|
|4. Check for nasal flaring and use of accessory muscles. Evaluate the patient for possible changes in skin color and capillary refill.||To assess the increase in respiratory effort and respiratory muscle fatigue. Assessing changes in skin color may reveal cyanosis that may cause a medical emergency.|
|5. Place the patient in a comfortable position or upright position or place the patient in high fowlers or semi fowlers position with the head of the bed elevated.||To help increase lung expansion and provide patients comfort. The comfort of the patient is very essential to help improve breathing patterns and helps in the stability of the patient’s condition.|
|6. Encourage the patient to cough, and do deep breathing exercises and techniques.||Deep breathing exercises help the patient to be comfortable and may help in relieving stress and promoting relaxation.|
|7. Maintain a patent airway at all times and suction secretion if necessary.||Encouraging coughing to release the secretions and suctioning if necessary may help in clearing secretions.|
|8. Monitor the patient from time to time and maintain proper positioning and keep comfortable at all times.||To evaluate the status of the patient for any changes in the breathing pattern.|
|9. Advise the patient to have small frequent meals positioned in an upright position.||Small frequent feedings may decrease the crowding on the diaphragm and let the diaphragm move freely.|
|10. Refer the condition of the patient accordingly to the physician if there are no changes in the breathing pattern.||Refer the condition of the patient to the physician to provide expert interventions if there are no changes in the breathing pattern. This can also help to provide pharmacological management as prescribed by the physician if needed.|
|11. Instruct the patient about pharmacological medications for pericardial effusion as prescribed by the physician. Explain the dosage, indications, and possible side effects of the medications. It is also important to ask the patient if there are any allergies to drugs before giving medications.||Informing the patient about the medication will promote safe administration and effectiveness of the medication. The nurse should also take note of any allergies to medication to prevent allergic reactions to medication.|
|12. Reassess the patient’s condition, vital signs, breathing pattern, depths, and characteristics. Reassess the ABG levels for any development or changes.||To evaluate the effectiveness of the interventions and pharmacological treatment. Reassessment is a great practice to help in developing more appropriate interventions that may help to treat patients’ ineffective breathing patterns.|
|13. Assess the patient’s ability to ambulate to determine if the patient can tolerate ambulation or if the patient still needs support when walking if the breathing pattern is at its normal rate.||Ambulation is encouraged because it can help improve blood circulation and blood flow.|
|14. Encourage the patient to interact with others like the patient’s relatives and significant others. Inform the patient’s carer to report if the patient shows any signs and symptoms of impaired breathing pattern.||Social support from the patient’s carer, relatives and significant others is very important to help ease anxiety.|
Pericardial Effusion Nursing Care Plan 6
Deficient Knowledge / Knowledge Deficit
Nursing Diagnosis: Knowledge Deficit related to pericardial effusion as manifested by verbalization of inaccurate information about the condition.
- The patient will verbalize their level of knowledge about the condition.
- The patient will enumerate accurate signs and symptoms of the condition.
- The patient will participate in the interventions for his condition.
- The patient will verbalize understanding and knowledge on how to cope with stress because of the condition.
|Nursing Interventions for Pericardial Effusion||Rationale|
|Assess the patient’s understanding of the condition. Assess the patient’s level of knowledge of the condition.||Assessment of the patient’s knowledge helps the nurse to provide an excellent way to build a teaching plan for the patient. Through assessment, the nurse will know the topics that the nurse should address first.|
|Assess the readiness of the patient to learn about the condition. The Nurse should also assess the level of the patient’s anxiety because of the condition.||The patient’s health may affect the ability of the patient to absorb new information. It is important to consider the proper timing of teaching the patient. Ask the patient about his/her perception of the situation.|
|Encourage patient participation in the development of the care plan and allow him/her to ask questions.||Planning care alongside the patient gives the patient sense of autonomy. If the patient is actively participating in the teaching the learning will be more effective.|
|Observe any possible barriers that would affect learning. Use teaching methods such as videos and articles about the condition so that the patient will easily understand.||Barriers to learning might be a factor for the patient to have difficulty learning about the condition. The Nurse should diminish information to the patient in a way that the patient will easily understand.|
|Acknowledge the participation of the patient during learning sessions. Allow the patient to ask questions and provide a learning-friendly environment.||Providing positive feedback and encouragement will give the patient more motivation. The patient will be able to express his/her perception of the condition if the nurse will show a learning-friendly environment.|
|Encourage the patient to communicate with his/her significant others, and relatives about his/her perception of the condition.||Social support from significant others and relatives can help relieve anxiety and stress. Involving the family of the patient in learning will also help the patient to cope with the condition.|
|Educate the patient as well as his relatives about the signs and symptoms of pericardial effusion, as well as its possible complications. Encourage the patient to note and report any symptoms that the patient may experience such as chest pain and difficulty breathing.||Knowledge about the condition and its warning signs and complications will help avoid complications and medical emergencies. The patient’s willingness to learn about the condition is very important in the promotion of his or her health.|
|8. Educate the patient about the medications, medical procedures, and surgery in some cases for patients with Pericardial effusion as prescribed by the physician.||Medications such as anti-inflammatory drugs are medications that are commonly used for patients with Pericardial Effusion. In some cases, the patient with Pericardial Effusion may undergo a medical procedure or surgery because the fluid from the pericardium needs to be drained.|
|9. Educate the patient on how to cope with stress, deep breathing exercises, and relaxation techniques.||Stress can cause an increased level of cortisol which is common in people with cardiac problems, reducing stress is very important for patients with pericardial effusion. The nurse should emphasize the importance of these techniques.|
|10. Educate the patient about the activities such as self-care and exercises that the patient with pericardial effusion be able to do as tolerated.||Knowledge about these activities may increase the patient’s tolerance to physical activities.|
|11. Evaluate the patient’s understanding of the condition before ending the teaching session.||Asking questions can help evaluate the patient’s understanding of the condition.|
More Nursing Diagnosis for Pericacardial Effusion
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. (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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