Page 155 - Critical Care Nursing Demystified

140 CRITICAL CARE NURSING DeMYSTIFIED

H ? How to Do It—Nursing Responsibilities

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ssess that c

1. Assess that consent form has been signed. Ensure time out is conducted.
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2. Obtain a pericardiocentesis tray, which includes a cardiac needle and an alliga-
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esis tra
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tor clip to attach the needle to an ECG machine.
3. Explain to the patient what is going to happen.
4. Make sure there is a patent IV line.
5. Administer sedation and monitor the airway for patency.
6. Take baseline VS and baseline ECG.
7. Have defibrillator and pacemaker available.
8. Obtain an ECG or echocardiogram machine. The alligator clip will be attached
to the ECG machine/echocardiogram after the physician inserts the cardiac 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.
needle under the xiphoid process into the heart.
9. Watch the ECG printout for ST segment elevation. This indicates that the nee-
dle is in the myocardium and needs to be pulled out slightly.
10. Prepare test tubes for specimens, if needed. The exudate may need to be
checked for cytology if a tumor is the most likely cause or if no cause is
known.
11. Observe the patient closely for signs of tamponade relief, which includes an
increasing BP, decreasing neck vein distention, and heart sounds increasing in
intensity.
12. Assist the physician with application of a pressure dressing just below the
xiphoid process.
13. Monitor the needle insertion site for bleeding. Observe, monitor for rhythm
disturbances.
14. Document the procedure and the patient’s tolerance.