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