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 pres- sure 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 ster- nal 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 gener- ated 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 fill- ing volume and to
offset any compressive effects of intrapericardial 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-spe- cific 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 done to evaluate for
uremic pericarditis and worsening renal status
Electrocardiography: used to monitor for S-T ele- vation, 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 with- out radiation, facial grimacing,
clutching of hands or chest, restlessness, diaphoresis, changes in pulse and
blood pressure, dyspnea
Altered tissue perfusion: curdiopulmonary,
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, short- ness 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.
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INTERVENTIONS
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RATIONALES
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Obtain vital signs. Obtain hemodynamic values, noting deviations
from baseline values.
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Provides information about the hemodynamics of the patient.
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Determine the presence and character of peripheral pulses,
capillary refill time, skin color and temperature.
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May indicate decreased perfusion resulting from impaired
coronary blood flow.
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Discourage any non-essential activity.
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Ambulation, exercise, transfers, and Valsalva type maneuvers can
increase blood pressure and decrease tissue perfusion.
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Monitor EKG for disturbances in conduction and for dysrhythmias
and treat as indicated.
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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.
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Titrate vasoactive drugs as ordered.
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Maintain blood pressure and heart rate at parameters set by MD
for optimal perfusion with minimal workload on heart.
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Administer oxygen by nasal cannula as ordered, with rate
dependent on disease process and condition.
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Provides oxygen necessary for tissues and organ perfusion.
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Auscultate lungs for crackles (rales), rhonchi, or wheezes.
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Suggestive of fluid overload that will further decrease tissue
perfusion.
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Auscultate heart sounds for S3 or S4 gallop, new murmurs,
presence of jugular vein distention, or hepatojugular reflex.
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Suggestive of impending or present heart failure.
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Monitor oxygen status with ABGs, SpO2, monitoring, or
with pulse oximetry.
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Provides information about the oxygenation status of the patient.
Continuous monitoring of saturation levels provide an in- stant analysis of
how activity can affect oxygenation and per- fusion.
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Assist patient with planned, graduated levels of activity.
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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.
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Discharge or Maintenance Evaluation
·
Lung fields will be clear and free of adventitious breath sounds.
·
Extremities will be warm, pink, with easily pal- pable pulses of
equal character.
·
Vital signs and hemodynamic parameters will be within normal
limits for 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.
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 respirations,
increased heart rate, increased blood pressure, difficulty concen- trating, dry
mouth, poor eye contact, decreased energy, irritability, crying, feelings of helplessness.
Knowledge deficit
See Miokard Infark
Related to: lack of understanding, lack of under- standing of medical
condition, lack of recall
Defining characteristics: questions regarding problems, inadequate follow-up on
instructions given, misconceptions, lack of improvement of previous regimen,
development of preventable complications
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