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Nursing Journal of India

Nursing management of patient with pericardial effusion

Nursing management of patient with pericardial effusion

Rajarajeswari, S

INTRODUCTION:

Pericardial effusion is an abnormal accumulation of fluid in the pericardial sac. Normally the pericardial sac contains less than 50 ml of fluid. In case of chronic pericarditis, advanced congestive heart failure or cardiac surgery, there may be chances of escape of more fluid into the pericardial sac. This condition may be referred as Pericardical effusion.

CASE STUDY

PATIENT HISTORY: A 25 year old man got admitted in hospital with the complaint of breathlessness, abdominal distress, cough, on and off temperature for 6 months. On examination, it was found that pallor present, JVP raised, Bronchial breathing and Dressler’s sign present, and Hepatomegaly present. He was clinically diagnosed to have congestive cardiac failure with Pericardial effusion.

DEFINITION OF PERICARDIAL EFFUSION:

It is accumulation of fluid in the pericardial’cavity.

ETIOLOGY:

Infective : Viral, Tuberculosis, Pyogenic, Mycotic Syphilitic Non-infective, such as Acute Myocardial infarction, Uremia, Myxedema

III Due to hypersensitivity or auto-immune mechanisms such as Rheumatic Carditis, Systemic Lupus Erythematosus (SLE), Rheumatoid Arthritis (RA)

PATHOPHYSIOLOGY:

Pericardial fluid may accumulate slowly without causing noticeable symptoms. A rapidly developing effusion however can stretch the pericardium to its maximum size & can cause decreased cardiac output and decreased venous return to the heart. The result is cardiac tamponade (compression of the heart). The characteristic sign of pericardia! effusion is an extension of flatness on percussion across the anterior aspect of the chest wall. The patient may complain of a feeling of fullness within the chest or have substantial or ill-defined pain.

SIGNS AND SYMPTOMS:

Symptoms:

Fever, Weight loss, Chest pain, Dyspnoea, Dry hacking cough, Hoarseness of voice, Dysphasia.

Signs :

Pulsus paradoxus, Kussamaul’s sign – Elevated JVP during inspiration, Apex beat within the cardiac dullness, Dressler’s sign – dull percussion note over lower half of sternum, Impaired note in right Cardio hepatic angle [Rotch’s sign], Faint or muffled heart sounds, Friction rub, Bronchial breathing below the angle of left scapula (Ewart or Pin sign)

INVESTIGATIONS:

1. X-ray chest PA view – shows cardiomegaly

2. Echocardiography Before pericardiocentesis, cardiac chambers are of normal dimension and, large pericardial effusion present. After pericardiocentesis, moderate pericardial effusion present.

Other Investigations

1. Blood Grouping (A&B) & Rh Typing (Rh+ve)

2. Hb (10.5 gm%), WBC (6700 Cubic mm), neutrophills (54%) Lymphocytes (49%) Eusimophile (2%), ESR (12/mm) BT(1^sup 1^20^sup 11^) CT (2’30”), Mantoux (-ve)

3. Pericardial Fluid

Total count (2000 / Cubic mm), (2000/cubic mm) Polymorphs (65%), Lymphocytes (35%), Total Proteins (4.0gm%), Gram stain (No organism seen) AFB (Negative).

TREATMENT:

Absolute bed rest, continuous cardiac monitoring with the help of cardiascope, recording vital signs.

MEDICAL MANAGEMENT:

Inj. Deriphyllin 2cc Im Q8H, Cap. Amoxycillin 250mg TDS, T. Avil 1HS.

SURGICAL MANAGEMENT:

Surgical treatment of effusion is of 3 parts:

1. Needle aspiration to relieve the tamponade

2. Tube drainage (used in intractable malignant effusion)

3. Pericardiectomy

For this patient (Pericadio-centesis, aspiration of fluid from pericardial sac with the help of needle) was done.

INDICATION:

1. Diagnostic

a. To establish the nature of fluid (Transudate or exudate)

b. For bacteriological studies

c. To isolate the malignant cells

d. For immunological studies of the fluid e.g. RH factor, IgG etc.

2. Therapeutic

a. To relieve cardio – respiratory embarrassment

b. To remove the blood or pus in order to prevent fibrosis

c. To install anti-malignant drugs

EQUIPMENTS:

1. Aspiration needle No.: 18

2. Three way stopcock

3. 20ml syringe

4. Sterile draps

PRE-REQUISITES

1. Patient’s formal consent

2. Normal BT, CT, & PT

3. Scope monitoring: continuous ECG Monitoring

4. Established intro – venous line which can be used to administer life saving drugs inclusive of anti arrhythmic drugs.

5. Emergency tray containing life saving drugs endotracheal tube & AMBU Bag

6. Shave the part [chest]

PROCEDURE:

Patient is given atropine and sedation half an hour to the procedure. He is then kept in supine position with head elevated to about 45 to 60 degree (placing the heart in close proximity to the chest wall, so that the needle can be inserted into the pericardial sac more easily). Cardiac scope is connected to the patient. Clean the part with savlon, ether and iodine – spirit, chest in draped with sterile towel. Local anaesthetic like 1% Xylocaine is infiltrated upto the pericardium at the selected site. An assembly of needle, syringe and three-way stopcock is introduced into the chest cavity at the selected site. The appearance of fluid into the syringe indicates entry in the pericardial cavity. After collecting adequate quantity of fluid, the needle is removed & Tincture Benzoin seal is applied at the site. While aspiration of fluid scope should be observed for ventricular premature contraction [VPC], appearance of multiple or runs of VPC requires stoppage of procedure. Checking and recording the vital signs is also significant during the procedure. The collected samples of fluid are to be sent for analysis (Biochemical, pathological, cell count AFB).

POSTPRROCEDURE ORDERS

1. Nil by mouth for 4 hours.

2. Scope monitoring

3. Watch for development of cardiac tamponade

4. Medications

– Inj. Cefataxime 1gm IV Bd

– Cap. Rifampicin 450mg od

– T. INH 300mg od

– Inj. Deriphyllin lamp Im Q8H

– Inj. Betneso 14mg. IV Q8H.

– T. Liv 52 2 tab tds

– Mild analgesics sos

5. Nasal O2 sos

6. TPR/BP/Intake-output chart

COMPLICATIONS:

1. Vaso – Vagal Shock

2. Ventricular arrhythmias

3. Penetration into the cardiac chamber

4. Development of cardiac tamponade

5. Infection

NURSING MANAGEMENT BEFORE PERICARDIOCENTESIS

1. Receive the patient in comfortable bed.

2. Keep the patient in supine position with head end elevated upto 45 to 60 degrees.

3. Check and record the vital signs at regular intervals.

4. Connect Cardiac scope for continuous cardiac monitoring. Inform the physician if any unusual changes seen in the ECG.

5. Explain the disease condition and treatment plan to the patient, at his level of understanding.

6. Provide him mental and moral support.

7. Take care that the patient is taking adequate amount of diet (Fluid & Soft diet).

8. Maintain intake and output chart.

9. If the patient is suffering from dysponea provide nasal O2.

10. Keep the IV line patient.

11. Send the prescribed investigations and collect all the reports.

12. Administer the prescribed medications at right time.

13Get the informed consent for the procedure from the patient.

14. Do the necessary sensitivity test to the patient (Xylocaine sensitivity test].

15. Set the articles.

16. Give the premeditations prescribed by the physician.

DURING PROCEDURE

1. Keep the patient in proper position.

2. Clean the parts with savlon, ether, iodine spirit.

3. Assist the physician for doing the procedure by providing the articles one by one in order.

4. Watch the scope monitor for any arrhythmias or VPC’s

5. Check the vital signs & record them.

6. Collect the specimen samples of the aspirated fluid.

7. After the needle is withdrawn, seal the site with Tincture benzoin.

8. Make sure that the patient is lying comfortably.

AFTER PROCEDURE

1. Check & record the vital signs.

2. Label the samples and send them for necessary investigations.

3. Continuous Cardiac – scope monitoring.

4. Watch for development of Cardiac tamponade.

5. Keep the patient nil by mouth for 4 hours.

6. Administer the prescribed medications.

7. Provide nasal O2 sos.

8. Record intake and output chart.

DISCHARGE ADVICE

1. Provide health education regarding diet plan, activities of daily living.

2. Explain the cardinal signs of pericardial effusion, so that he can come for treatment at an early stage if recurrence occurs.

3. Insist on him the importance of taking the medications regularly.

4. Advice him to attend cardiac OPD regularly.

BIBLIOGRAPHY:

1. Suzanne C. Smeltzer / Brenda G. Bare; Brunner G. Suddarth’s Text book of Medical and Surgical nursing, 7th edition, J. B. Lippincott company, Philadelphia, 1992, pg-no. 699-700.

2. Kirtic C. Patel / Nitin M. Rathod / Pragna Pai, Clinical Medicine, 1st edition, K.C. Patel N.M. Rathod, Mumbai, April 1992, Pg-No: 114-115, 384.

3. Harrisons, Principles of internal medicine, 13th edition, volume (1), MC Graw Hill inclusion Health professions. Divisions, New York, 1994, Pg-No. 1095- 1096, 1098.

S. Rajarajeswari

Author:

B. Sc., (N), Staff Nurse Govt. General Hospital, Karaipal.

Copyright Trained Nurses’ Association of India Jun 2003

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