1-38
1-38. CARDIAC TAMPONADE
Bleeding into the pericardial sac, or accumulation of fluid in the pericardial sac, results in compression of the heart. This compression reduces heart movement, prevents adequate filling of the ventricles, and obstructs venous return to the heart. This condition, called cardiac tamponade, is an emergency that requires prompt relief to prevent death from circulatory failure.
a. Signs and Symptoms.
(1) Distention of the neck veins.
(2) Weak pulse.
(3) Low pulse pressure.
NOTE: Delayed distention of the neck veins should not be confused with the transitory distention seen postoperatively as the patient throws off unconsciousness produced by anesthesia. This distention is usually the result of straining.
b. Nursing Implications.
(1) Report signs and symptoms to the RN immediately.
(2) Monitor pulse and blood pressure.
(3) Administer oxygen as ordered for dyspnea.
(4) Assist with diagnostic procedures such as chest X-ray, ECG, or cardiac catheterization.
(5) Assist with procedures to relieve pressure and remove fluid such as thoracotomy or needle aspiration of the pericardial cavity.
