Nursing Diagnoses!!

When treating a patient with cardiac tamponade, a nurse keeps specific nursing diagnoses in mind.  I have included some of the possible nursing diagnoses in this post.

Nursing Diagnosis: Decreased cardiac output related to reduced ventricular filling secondary to increased intrapericardial pressure.

Outcome Criteria:

• Patient alert and oriented
• Skin warm and dry
• Pulses strong and equal bilaterally
• Capillary refill <3 sec
• HR 60 to 100 beats/min
• BP 90 to 120 mm Hg
• Pulse pressure 30 to 40 mm Hg
• Urine output 30 ml/hr or 1 ml/kg/hr

Plan/ Interventions:

• Patient monitoring:
• Continuously monitor ECG for dysrhythmia formation
• Monitor the BP every 5 to 15 minutes during the acute phase.
• Monitor for pulsus paradoxus 
• Monitor urine output hourly

• Patient Assessment
• Assess cardiovascular status
• Note skin temperature, color, and capillary refill.
• Assess level of consciousness

• Patient Management
• Provide supplemental oxygen as ordered.
• Initiate two large-bore intravenous lines for fluid administration
• Pharmacologic therapy
• Monitor the patient for dysrhythmias

[Above info adapted from http://nursingcrib.com/critical-care-and-emergency-nursing/cardiac-tamponade/]

Other possible nursing diagnoses include:

• Risk for deficient fluid volume
• Impaired urinary elimination
• Risk for infection
• Death anxiety

Nurses Role In Cardiac Tamponade

What is the role of the nurse in caring for a patient with a cardiac tamponade?

There are a few scenarios where a nurse might come into contact with a patient experiencing a cardiac tamponade.  First, the nurse might be working in the ER and a patient with a tamponade arrives.  On the other hand, the nurse could be working on an ICU and the patient develops a tamponade while she is caring for the patient.  

In either case, nursing care is going to be similarly centered around quickly and accurately assessing the patient.  As a nurse caring for a patient, our highest priority is always making sure the patient has adequate airway, breathing, and circulation (the ABC's).  A change in any of these requires immediate intervention.  If the patient becomes hypoxic due to poor cardiac output, we may need to initiate oxygenation, intubation, or ventilation.  Our assessments of the patient need to include cardiac function (looking at BP, HR, JVD, etc), skin signs (give us information on tissue perfusion), and level of conciousness (which may be the first thing to change when a patient's status begins to decline).  If a patient is currently on telemetry it is the nurses role to check his ECG changes and status.  

If the patient does not have adequate IV access, the nurse should start two large bore IV lines.  These will be used if the patient requires fluid resuscitation, blood products, or IV drugs.  Having quick access to emergency resuscitation is also important in case the patient declines enough to need resuscitation.  

Often overlooked, however, is some of the most important care that a nurse can provide, emotion support.  If the patient is awake, or if the patient's family is present, the nurse should act in a controlled calm manner throughout any emergent situation and should attempt to calmly explain any procedure.  A patient awake through any of these experiences is going to have a very high level of anxiety.  We, as nurses, need to make sure we are caring for our patients holistically, not just treating their disease.  

For more information of nursing care of patient's with cardiac tamponade please visit these two websites:

http://nursingcrib.com/critical-care-and-emergency-nursing/cardiac-tamponade/

http://www.enurse-careplan.com/2010/06/nursing-care-plan-ncp-cardiac-tamponade.html

I used these resources because they are excellent at presenting a background of the disease, as well as the role of the nurse in caring for patient's with cardiac tamponade.  The first site breaks down the assessments and signs and symptoms nicely.  The second does a great job of giving slightly more advanced nursing interventions and details that the first did not.       

Treatments

When dealing with cardiac tamponade, how do we treat and reverse the disease?

The only useful method of treatment for cardiac tamponade is to remove the pericardial fluid causing the restrictions on the heart.  We can give supportive treatments as well, such as, fluid resuscitation or inotropic agents that reduce the strength of heart contractions.

There are two ways to drain the fluid surrounding the heart,  percutaneous drainage (pericardiocentesis) or surgical drainage.

Pericardiocentesis:
Basically, a catheter is inserted into the pericardial sac through the chest wall, usually through the infrasternal angle.  Echocardiography is used during the procedure to ensure accurate insertion and to prevent puncturing a lung.

(http://www.medivisuals1.com/tamponadeandpericardiocentesis-30321602x.aspx)

Surgical drainage:

The surgeon will creates an opening in the chest wall under the sternum to visualize the pericardium. Surgical drainage has the advantages of permitting diagnostic pericardial biopsies to be taken and pericardiectomy to be performed, if needed. Direct surgical visualization may also be preferable if fluid has reaccumulated after catheter drainage, the effusion is loculated, there is a special need for biopsy material, or the patient has a coagulopathy. However, surgical drainage requires general anesthesia, which may worsen hemodynamic compromise if needle drainage is not performed first to reduce the severity of the cardiac tamponade.

(http://www.sciamsurgery.com/sciamsurgery/institutional/figTabPopup.action?bookId=ACS&linkId=part04_ch12_fig4&type=fig)

There are two reasons that pericardiocentesis cannot be performed.  Severe pulmonary hypertension can lead to a worsening of right heart function if the effusion is removed because the pressure was supporting the right ventricle. If the patient has coagulopathy, inserting a needle into their chest cavity and risking puncturing their liver can be extremely life threatening and should be avoided.  

Reference:

Holt, B. (2014, October 8). Cardiac Tamponade. Retrieved February 19, 2015, from http://www-uptodate-com.offcampus.lib.washington.edu/contents/cardiac-tamponade?source=search_result&search=cardiac tamponade&selectedTitle=1~150

Common Signs and Symptoms

What are the signs and symptoms that are most commonly found in patients with cardiac tamponade?

One study I researched followed 56 patients diagnosed with cardiac tamponade.  In the table below, I summarized the results of the most common physical findings.  Many of the patients had a few of these different findings, hence the percentages do not add up to 100%.  Furthermore, I left out the less common findings to give a more succinct impression of the typical cases.

Physical Finding	Percentage of patients
Respiratory rate > 20/min	80%
Heart rate > 100 beats/min	77%
Paradoxical pulse > 20 mmHg	77%
Systolic blood pressure > 100 mmHg	64%
Hepatomegaly	55%

Probably the most uncomfortable aspect of these would be experiencing your heart beat begin to race and your breathing increase.  Often, such as in heart attacks, people will describe a feeling of impending doom.  If a patient has a severe progressing tamponade however, they will enter cardiac arrest relatively quickly and CPR will need to be performed.  

References:

Guberman, B., Fowler, N., Engel, P., Gueron, M., & Allen, J. (1981). Cardiac tamponade in medical patients. Circulation, 64, 633-640. Retrieved February 6, 2015, from http://circ.ahajournals.org/content/64/3/633.full.pdf html

Diagnosis

How do we diagnose someone with a Cardiac Tamponade?  Well, it involves using clinical judgement and diagnostic imaging. Since cardiac tamponade is a form of shock, we would expect to see symptoms of poor cardiac perfusion, tachycardia because the heart is having to beat faster due to restriction in movement, and hypotension.  However, most psychical symptoms are fairly nonspecific, so using diagnostic imaging is the best method of diagnosis.  (Spodick, 2003)

The best and easiest method of diagnosis, is performing an echocardiogram or "echo." An echocardiogram uses ultrasound waves to view the heart in motion.  The ultrasound tech will move the transducer around the pericardium to get a view of all portions of the heart in motion.  This will provide an excellent view of an heart defects, or signs of cardiac tamponade.  (Echocardiogram)

(http://www.severinbrenny.com/echocardiogram.html)

And here we have an actual echo of a heart with a pericardial effusion (cardiac tamponade).  We can clearly see the chambers of the heart, but then we notice a large sac around the heart.  This is very abnormal.

(http://www.stritch.luc.edu/lumen/MedEd/Radio/curriculum/Medicine/Pericardial_effusion2.htm)

Echocardiogram. (n.d.). Retrieved February 2, 2015, from http://www.severinbrenny.com/echocardiogram.html

Spodick, D. (2003). Current concepts: acute cardiac tamponade. New England Journal Of Medicine, 349(7), 684-690.

Cardiac Tamponade? Tell me more!

This week I began to look into the pathophysiology of Cardiac Tamponade, that is, what happens during a cardiac tamponade? I found a fantastic YouTube video that explains a cardiac tamponade very well.  It is a cheesy hand drawn video, but it keeps it simple and is entertaining to watch.

Excellent explanation of Cardiac Tamponade

Basically, the sac surrounding the heart tissue fills up with some sort of fluid.  This reduces the amount of space the heart has to pump.  As the sac fills with fluid, the heart becomes more constricted and cannot contract effectively.

Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier

Since the pericardial sac is not flexible, it cannot expand very much with the increased fluid volume. This increases the pressure on the heart.  As the pressure builds, the stroke volume of the heart begins to decrease.  Eventually, obstructive shock develops, leading to cardiac arrest if left untreated.  

Mortality from cardiac tamponade is 100% if left untreated, or if the fluid isn't removed.  

Citation

Hasan Ali Gumrukcuoglu, Dolunay Odabasi, Serkan Akdag, and Hasan Ekim, “Management of Cardiac Tamponade: A Comperative Study between Echo-Guided Pericardiocentesis and Surgery—A Report of 100 Patients,” Cardiology Research and Practice, vol. 2011, Article ID 197838, 7 pages, 2011. doi:10.4061/2011/197838

Epidemiology of Cardiac Tamponade

Who gets a cardiac tamponade??

Good question. After doing quite a bit of research, it has become clear that the numbers of cardiac tamponade are poorly documented in the United States. I was unable to find a clear article that covered the distribution of cardiac tamponade.  However, I found some information regarding those most at risk.  

First of all, it seems that cardiac tamponade occurs in about 2 out of 10,000 cases.  In younger ages, most cases of cardiac tamponade are caused by trauma or HIV, but in the elderly patients, it is more commonly associated with malignancy and/or renal failure.  In the younger ages, there is generally more cases of boys than of girls with cardiac tamponade. 

In one study I looked into, they researched the cause of 106 cases of pericardial effusion.  They found that the most prominent causes were cancer (36%), idiopathic (30%), meaning there was no known cause, and infection (21%).  

In another study, they examined the frequency of pericardial effusions in patients with HIV.  The study found that of their 187 patients with pericardial effusions, approximately 14 of them were positive for HIV.  

Another study concluded that there is a much higher incidence of pericardial effusion in patients with AIDS.  Also, the development of effusion in patients with HIV suggests the transition to AIDS.

So while it is hard to determine the exact numbers of cardiac tamponade in the United States, we know that it is more prevalent in certain populations.  

References:

Eisenberg, M., Gordon, A., & Schiller, N. (1992). HIV-associated pericardial effusions. Chest, 102(3), 956-958.

Richardson, L. (2014). Cardiac tamponade. JAAPA: Journal Of The American Academy Of Physician Assistants (Lippincott Williams & Wilkins), 27(11), 50-51. doi:10.1097/01.JAA.0000455653.42543.8a