Emergency Nursing Care Plan: PERICARDITIS


Pericarditis is an inflammation of the pericardium that can occur due to a variety of circumstances. The inflammation is usually a manifestation of another disease process but may be drug induced, from agents such as procainamide, hydralazine, phenytoin, penicillin, phenylbutazone, minoxidil, or daunorubicin. Other causes for pericarditis include idiopathic causes, viral, bacterial, fungal, protozoal, uremia, MI, tuberculosis, neoplasms, trauma, surgical procedures, autoimmune disorders (lupus, rheumatoid arthritis, scleroderma), inflammatory disorders (amyloidosis), dissecting aortic aneurysms, or radiation treatments to the thorax.
Pericarditis may be classified as acute or chronic, as well as constrictive or restrictive. Constrictive pericarditis occurs when fibrin material is deposited on the pericardium and adhesions form between the epicardium and pericardium. Restrictive pericarditis results when effusion into the pericardial sac occurs. Both types cause interference with the heart’s ability to fill properly, which causes increases in systemic and pulmonary venous pressures. Eventually systemic blood pressure and cardiac output decrease.
The visceral pericardium is a serous membrane that is separated from a fibrous sac, or parietal pericardium, by a small (less than 50 cc) amount of fluid. If the fluid increases to the point where the heart function is compromised, pleural effusion occurs and cardiac tamponade becomes a critical concern. The pericardium is important because it holds the heart in a fixed position to minimize friction between it and other structures. Other functions include prevention of exercise- or hypervolemic induced dilatation of the cardiac chambers and assistance with atrial filling during systole.
The main symptoms of pericarditis include sharp, retrosternal and/or left precordial pain that worsens while in a supine position, and a pericardial friction rub best auscultated at the lower left sternal border. The pain may be exacerbated by coughing, swallowing, breathing, or twisting. Other symptoms may be seen depending on the severity of the pericarditis and the rapidity in which the fluid accumulates. Volumes of 100 cc that accumulates quickly may produce a more life-threatening complication, cardiac tamponade, than a larger accumulation of fluid that is generated over a long period of time.

MEDICAL CARE
Oxygen: to increase available oxygen supply Analgesics: morphine or meperidine used to alleviate pain Steroids: large doses of corticosteroids, such as prednisone, are given to reduce inflammation and control the symptoms of pericarditis
NSAIDs: aspirin or indomethacin are used to reduce fever and inflammation IV fluids: given to help restore left ventricular filling volume and to offset any compressive effects of intra pericardial pressure increases
Inotropic drugs: isoproterenol or dobutamine IV given for their positive inotropic effects as well as peripheral vasodilating properties
Laboratory: white blood cell count may be elevated, sed rate may be elevated from non-specific inflammatory response; CKMB may be mildly elevated; blood cultures done to identify organism responsible for infective process and to ascertain appropriate drug for eradication; renal profile was done to evaluate for uremic pericarditis and worsening renal status
Electrocardiography: used to monitor for S-T elevation, T wave changes associated with pericarditis, and to monitor for dysrhythmias
Echocardiography: used to establish presence of pericardial fluid and an estimate of volume, any vegetation on valves, and to observe for right atrium and right ventricular dilatation
Chest x-ray: used to show cardiomegaly and to assess lung fields Pericardiocentesis: used to relieve fluid build-up and pressure in emergency situations where the patient is deteriorating or is in shock
Surgery: open surgical drainage is usually the treatment of choice for cardiac tamponade

NURSING CARE PLANS
Alteration in comfort
Related to: chest pain due to pericardial inflammation
Defining characteristics: chest pain with or without radiation, facial grimacing, clutching of hands or chest, restlessness, diaphoresis, changes in pulse and blood pressure, dyspnea
Altered tissue perfusion: cardiopulmonary, renal, peripheral, cerebral
Related to: tissue ischemia, reduction or interruption of blood flow, vasoconstriction, hypovolemia, shunting, depressed ventricular function, dysrhythmias, conduction defects
Defining characteristics: abnormal hemodynamic readings, dysrhythmias, decreased peripheral pulses, cyanosis, decreased blood pressure, shortness of breath, dyspnea, cold and clammy skin, decreased mental alertness and changes in mental status, oliguria, anuria, sluggish capillary refill, abnormal electrolyte and digoxin levels, hypoxia, ABG changes, chest pain, ventilation-perfusion imbalances, changes in peripheral resistance, impaired oxygenation of myocardium, EKG changes (S-T segment, T wave, U wave), LV enlargement, palpitations, abnormal renal function studies.
Outcome Criteria
·        Blood flow and perfusion to vital organs will be preserved and circulatory function will be maximized.
·        Patient will be free of dysrhythmias.
·        Hemodynamic parameters will be within normal limits.

INTERVENTIONS
RATIONALES
Obtain vital signs. Obtain hemodynamic values, noting deviations from baseline values.
Provides information about the hemodynamics of the patient.

Determine the presence and character of peripheral pulses, capillary refill time, skin color and temperature.
May indicate decreased perfusion resulting from impaired coronary blood flow.
Discourage any non-essential activity.



Ambulation, exercise, transfers, and Valsalva type maneuvers can increase blood pressure and decrease tissue perfusion.
Monitor EKG for disturbances in conduction and for dysrhythmias and treat as indicated.


Decreased cardiac perfusion may instigate conduction abnormalities. Dysrhythmias may occur due to compromised function of ventricles due to pressure exerted on them by excess fluid.
Titrate vasoactive drugs as ordered.

Maintain blood pressure and heart rate at parameters set by MD for optimal perfusion with the minimal workload on the heart.
Administer oxygen by nasal cannula as ordered, with rate dependent on disease process and condition.
Provides oxygen necessary for tissues and organ perfusion.

Auscultate lungs for crackles (rales), rhonchi, or wheezes.
Suggestive of fluid overload that will further decrease tissue perfusion.
Auscultate heart sounds for S3 or S4 gallop, new murmurs, the presence of jugular vein distention, or hepatojugular reflex.
Suggestive of impending or present heart failure.
Monitor oxygen status with ABGs, SpO2, monitoring, or with pulse oximetry.



Provides information about the oxygenation status of the patient. Continuous monitoring of saturation levels provides an instant analysis of how activity can affect oxygenation and perfusion.
Assist patient with planned, graduated levels of activity.


Allows for balance between rest and activity to decrease myocardial workload and oxygen demand. Gradual increases help to increase patient tolerance to activity without pain occurring.

Discharge or Maintenance Evaluation
·        Lung fields will be clear and free of adventitious breath sounds.
·        Extremities will be warm, pink, with easily palpable pulses of equal character.
·        Vital signs and hemodynamic parameters will be within normal limits for the patient. Oxygenation will be optimal as evidenced by pulse oximetry greater than 90%, Sv02 greater than 75%, or normal ABGs.
·        Patient will be free of chest pain and shortness of breath. The patient will be able to verbalize information correctly regarding medications, diet and activity limitations.
Decreased cardiac output
See Miokard Infark
Related to: fluid in pericardial sac from pericardial effusion, potential for cardiac tamponade because of effusion, damaged myocardium, decreased contractility, dysrhythmias, conduction defects, alteration in preload, alteration in afterload, vasoconstriction, myocardial ischemia, ventricular hypertrophy
Defining characteristics: decreased blood pressure, tachycardia, pulsus paradoxus greater than 10 mmHg, distended neck veins, increased central venous pressure, dysrhythmias, decreased QRS voltage or electrical alternans, diminished heart sounds, dyspnea, friction rub, cardiac output less than 4 L/min, cardiac index less than 2.5 L/min/m’

Anxiety
See Miokard Infark
Related to: change in health status, fear of death, threat to body image, threat to role functioning, pain.
Defining characteristics: restlessness, insomnia, anorexia, increased respiration, increased heart rate, increased blood pressure, difficulty concentrating, dry mouth, poor eye contact, decreased energy, irritability, crying, feelings of helplessness.

Knowledge deficit
See Miokard Infark
Related to: lack of understanding, lack of understanding of medical condition, lack of recall

Defining characteristics: questions regarding problems, inadequate follow-up on instructions given, misconceptions, lack of improvement of the previous regimen, development of preventable complications.


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