Cardiac Tamponade

  1. General information
    1. An accumulation of fluid/blood in the pericardium that prevents adequate ventricular filling; without emergency treatment client will die in shock.
    2. Caused by blunt or penetrating chest trauma, malignant pericardial effusion; can be a complication of cardiac surgery
  2. Medical management: emergency treatment of choice is pericardiocentesis (insertion of a needle into the pericardial sac to aspirate fluid/blood and relieve the pressure on the heart)
  3. Assessment findings
    1. Chest pain
    2. Hypotension, distended neck veins, tachycardia, muffled or distant heart sounds, paradoxical pulse, pericardial friction rub
    3. Elevated CVP, decreased Hgb and Hct if massive hemorrhage
    4. Diagnostic test: chest x-ray reveals enlarged heart and widened mediastinum.
  4. Nursing interventions
    1. Administer oxygen therapy
    2. Monitor CVP/IVs closely
    3. Assist with pericardiocentesis.
      1. Monitor ECG, blood pressure, and pulse.
      2. Assess aspirated fluid for color, consistency.
      3. Send specimen to lab immediately.

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