Page 154 - Critical Care Nursing Demystified

Chapter 3 CARE OF THE PATIENT WITH CRITICAL CARDIAC AND VASCULAR NEEDS 139

If the tamponade develops quickly, as in the case of blunt or penetrating
trauma, a medical emergency can result unless pressure around the heart is
relieved ASAP.

Interpreting Test Results
Echocardiogram can show fluid around the heart and compression of under-
lying structures.
ECG can show electrical alternans where one QRS is taller, alternating with
a QRS that is shorter.
Chext x-ray (CXR) shows fluid accumulation around the pericardial sac.

Nursing Diagnoses for Cardiac
Tamponade Expected Outcomes
Decreased CO due to pressure on the The patient will have a stable
myocardium from fluid around the BP >100
pericardial sac JVD will be normal
Heart sounds will be clear Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.

Interventions

Administer 100% oxygen ASAP via nonrebreather mask to help improve
myocardial oxygenation.
Establish an IV line to help with emergency medications prn.
Obtain a stat 12-lead ECG as cardiac tamponade can mimic an MI.
Obtain a chest x-ray, which will show an enlarged cardiac silhouette that
occurs with a large cardiac effusion.
Prepare to administer cardiac contractility stimulators like dobutamine to
improve the functioning of the myofibrils.
Prepare for an emergency thoracotomy if there are penetrating cardiac
injuries.
Prepare for a pericardiocentesis (an echocardiogram-guided needle aspira-
tion); if fluid is from a pericardial effusion it can be removed by this
method.
Prepare the patient for a pericardial window, which is done by thoracotomy
if fluid recurs.