NURSING PROCESS: THE PATIENT WITH PERICARDITIS
The primary symptom of the patient with pericarditis is pain, which is assessed by observing and evaluating the patient in var-ious positions. While observing the patient, the nurse tries to dis-cover whether the pain is influenced by respiratory movements, with or without the actual passage of air; by flexion, extension, or rotation of the spine, including the neck; by movements of the shoulders and arms; by coughing; or by swallowing. Recognizing the events that precipitate or intensify pain may help establish a diagnosis and differentiate the pain of pericarditis from the pain of myocardial infarction.
A pericardial friction rub occurs when the pericardial surfaces lose their lubricating fluid because of inflammation. The rub is audible on auscultation and is synchronous with the heartbeat. However, it may be elusive and difficult to detect.
If there is difficulty in distinguishing a pericardial friction rub from a pleural friction rub, patients are asked to hold their breath; a pericardial friction rub will continue.
The patient’s temperature is monitored frequently. Pericardi-tis may cause an abrupt onset of fever in a patient who has been afebrile.
Based on the assessment data, the major nursing diagnosis of the patient may include:
· Acute pain related to inflammation of the pericardium
Based on the assessment data, potential complications that may develop include:
· Pericardial effusion
· Cardiac tamponade
The patient’s major goals may include relief of pain and absence of complications.
Relief of pain is achieved by having the patient rest. Because sit-ting upright and leaning forward is the posture that tends to re-lieve pain, chair rest may be more comfortable. It is important to instruct the patient to restrict activity until the pain subsides. As the chest pain and friction rub abate, activities of daily living mayresume gradually. If the patient is receiving medications such as analgesics, antibiotics, or corticosteroids for the pericarditis, his or her responses are monitored and recorded. If chest pain and friction rub recur, bed or chair rest resumes.
If the patient does not respond to medicalmanagement, fluid may accumulate between the pericardial lin-ings or in the sac. This condition is called pericardial effusion . Fluid in the pericardial sac can constrict the myo-cardium and interrupt its ability to pump. Cardiac output de-clines with each contraction. Failure to identify and treat this problem can lead to the development of cardiac tamponade and the possibility of sudden death.
The signs and symptoms of cardiac tam-ponade begin with falling arterial pressure. Usually, the systolic pressure falls while the diastolic pressure remains stable; hence, the pulse pressure narrows. Heart sounds may progress from sounding distant to being imperceptible. Neck vein distention and other signs of rising central venous pressure are observed. These signs and symptoms occur because, as the fluid-filled peri-cardial sac compresses the myocardium, blood continues to return to the heart from the periphery but cannot flow into the heart to be pumped back into the circulation.
In such situations, the nurse notifies the physician immediately and prepares to assist with pericardiocentesis . The nurse stays with the patient and continues to assess and record signs and symptoms while intervening to decrease the patient’s anxiety.
Expected patient outcomes may include:
1) Is free of pain
a) Performs activities of daily living without pain, fatigue, or shortness of breath
b) Temperature returns to normal range
c) Exhibits no pericardial friction rub
2) Absence of complications
a) Sustains blood pressure in normal range
b) Has heart sounds that are strong and can be auscultated
c) Shows absence of neck vein distention