Primary Nursing Diagnosis

Decreased cardiac output related to decreased preload and contractility.

OUTCOMES. Circulation status; Cardiac pump effectiveness; Tissue perfusion: Abdominal organs and peripheral; Vital signs status; Fluid balance

INTERVENTIONS. Cardiac care: Acute, Fluid/electrolyte management, Fluid monitoring; Shock management: Volume, Medication administration, Circulatory care


The highest priority is to make sure the patient has adequate airway, breathing, and circulation (ABCs). If the patient suffers hypoxia as a result of decreased cardiac output and poor tissue perfusion, oxygen, intubation, and mechanical ventilation may be required. If the

184 Cardiac Tamponade symptoms are progressing rapidly, the physician may elect to perform a pericardiocentesis to normalize pericardial pressure, allowing the heart and coronary arteries to fill normally, so that cardiac output and tissue perfusion are restored. Assist by elevating the head of the bed to a 60-degree angle to allow gravity to pull the fluid to the apex of the heart. Emergency equipment should be nearby because ventricular tachycardia, ventricular fibrillation, or laceration of a coronary artery or myocardium can cause shock and death. Pericardiocentesis usually causes a dramatic improvement in hemodynamic status. However, if the patient has had rapid bleeding into the pericardial space, clots may have formed that block the needle aspiration. A "false-negative" pericardiocentesis is therefore possible and needs to be considered if symptoms continue.

The patient must be taken to surgery after this procedure to explore the pericardium and stop further bleeding. If the patient has developed sudden bradycardia (heart rate <50 beats per minute), severe hypotension (systolic blood pressure <70 mm Hg), or asystole, an emergency thoracotomy may be performed at the bedside to evacuate the pericardial sac, control the hemorrhage, and perform internal cardiac massage if needed. The patient may also require fluid resuscitation agents to enhance cardiac output.



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