Chapter 29 Management of Patients With Structural, Infectious, and Inflammatory Cardiac Disorders
PERICARDITIS
Pericarditis refers to an inflammation of the pericardium, the
membranous sac enveloping the heart. It may be a primary ill-
ness, or it may develop in the course of a variety of medical and
surgical disorders. The incidence of pericarditis varies with the
cause. For example, pericarditis occurs after pericardectomy
(opening of the pericardium) in 5% to 30% of patients after car-
diac surgery (Beers et al., 1999). Pericarditis that occurs within
10 days to 2 months after acute myocardial infarction (Dressler’s
syndrome) causes 1% to 3% of all cases of pericarditis (Beers et al.,
1999). Pericarditis may be acute or chronic. It may be classified
by the layers of the pericardium becoming attached to each other
(adhesive) or by what accumulates in the pericardial sac: serum
(serous), pus (purulent), calcium deposits (calcific), clotting proteins
(fibrinous), or blood (sanguinous).
Pathophysiology
The following are some of the causes underlying or associated
with pericarditis:
• Idiopathic or nonspecific causes
• Infection: usually viral (eg, Coxsackie, influenza); rarely
bacterial (eg, streptococci, staphylococci, meningococci,
gonococci); and mycotic (fungal)
• Disorders of connective tissue: systemic lupus erythemato-
sus, rheumatic fever, rheumatoid arthritis, polyarteritis
• Hypersensitivity states: immune reactions, medication re-
actions, serum sickness
• Disorders of adjacent structures: myocardial infarction,
dissecting aneurysm, pleural and pulmonary disease
(pneumonia)
• Neoplastic disease: caused by metastasis from lung cancer
or breast cancer, leukemia, and primary (mesothelioma)
neoplasms
• Radiation therapy
• Trauma: chest injury, cardiac surgery, cardiac catheterization,
pacemaker implantation
• Renal failure and uremia
• Tuberculosis
Pericarditis can lead to an accumulation of fluid in the peri-
cardial sac (pericardial effusion) and increased pressure on the
heart, leading to cardiac tamponade (see Chap. 30). Frequent or
prolonged episodes of pericarditis may also lead to thickening and
decreased elasticity that restrict the heart’s ability to fill properly
with blood (constrictive pericarditis). The pericardium may be-
come calcified, further restricting ventricular expansion during
ventricular filling (diastole). With less filling, the ventricles pump
out less blood, leading to decreased cardiac output and signs and
symptoms of heart failure. Restricted diastolic filling may result
in increased systemic venous pressure, causing peripheral edema
and hepatic failure.
Clinical Manifestations
The most characteristic symptom of pericarditis is chest pain, al-
though pain also may be located beneath the clavicle, in the neck,
or in the left scapula region. The pain or discomfort usually re-
mains fairly constant, but it may worsen with deep inspiration
and when lying down or turning. It may be relieved with a forward-
leaning or sitting position. The most characteristic sign of peri-
carditis is a friction rub. Other signs may include mild fever,
783
increased white blood cell count, and increased erythrocyte sedi-
mentation rate (ESR). Dyspnea and other signs and symptoms of
heart failure may occur as the result of pericardial compression
due to constrictive pericarditis or cardiac tamponade.
Assessment and Diagnostic Findings
Diagnosis is most often made on the basis of the patient’s history,
signs, and symptoms. An echocardiogram may detect inflamma-
tion and fluid build-up, as well as indications of heart failure, and
help to confirm the diagnosis. Because the pericardial sac sur-
rounds the heart, a 12-lead ECG detects ST changes in many, if
not all, leads.
Medical Management
The objectives of management are to determine the cause, ad-
minister therapy, and be alert for cardiac tamponade. When car-
diac output is impaired, the patient is placed on bed rest until the
fever, chest pain, and friction rub have subsided.
Analgesics and NSAIDs such as aspirin or ibuprofen may be
prescribed for pain relief during the acute phase. They also
hasten the reabsorption of fluid in the patient with rheumatic
pericarditis. Corticosteroids (eg, prednisone) may be prescribed
if the pericarditis is severe or if the patient does not respond
to NSAIDs. Colchicine may also be used as an alternative
medication.
Pericardiocentesis, a procedure in which some of the pericar-
dial fluid is removed, may be performed to assist in the identifi-
cation of the causative agent. It may also relieve symptoms,
especially if there are signs and symptoms of heart failure. A peri-
cardial window, a small opening made in the pericardium, may
be performed to allow continuous drainage into the chest cavity.
Surgical removal of the tough encasing pericardium (pericar-
diectomy) may be necessary to release both ventricles from the
constrictive and restrictive inflammation.
Nursing Management
The nurse caring for the patient with pericarditis must be alert to
the possibility of cardiac tamponade.
NURSING ALERT Nursing assessment skills are key to antici-
! pating and identifying the triad of symptoms of cardiac tamponade:
falling arterial pressure, rising venous pressure, and distant heart
sounds.
Patients with acute pericarditis require pain management with
analgesics, positioning, and psychological support. Patients
experiencing chest pain often benefit from education and reas-
surance that the pain is not a heart attack. To minimize compli-
cations, the nurse educates and assists the patient with activity
restrictions until the pain and fever subside. As the patient’s con-
dition improves, the nurse encourages gradual increases of activity.
If pain, fever, or friction rub reappear, however, activity restric-
tions must be resumed. The nurse educates the patient and
family about a healthy lifestyle to enhance the patient’s immune
system.
The nurse monitors the patient for heart failure. A patient
who is hemodynamically unstable or experiencing congestion
is treated the same as a patient with acute heart failure (see
Chap. 30).
784 Unit 6 CARDIOVASCULAR, CIRCULATORY, AND HEMATOLOGIC FUNCTION
NURSING PROCESS:
THE PATIENT WITH PERICARDITIS
Assessment
The primary symptom of the patient with pericarditis is pain,
which is assessed by observing and evaluating the patient in var-
ious positions. While observing the patient, the nurse tries to dis-
cover whether the pain is influenced by respiratory movements,
with or without the actual passage of air; by flexion, extension, or
rotation of the spine, including the neck; by movements of the
shoulders and arms; by coughing; or by swallowing. Recognizing
the events that precipitate or intensify pain may help establish a
diagnosis and differentiate the pain of pericarditis from the pain
of myocardial infarction.
A pericardial friction rub occurs when the pericardial surfaces
lose their lubricating fluid because of inflammation. The rub is
audible on auscultation and is synchronous with the heartbeat.
However, it may be elusive and difficult to detect.
NURSING ALERT A pericardial friction rub is diagnostic of peri-
carditis. The nurse should search diligently for the rub by placing
the diaphragm of the stethoscope tightly against the thorax and
! auscultating the left sternal edge in the fourth intercostal space, the
site where the pericardium comes into contact with the left chest
wall. A pericardial friction rub has a scratching or leathery sound.
The rub is louder at the end of exhalation and may be heard best
with the patient sitting and leaning forward.
If there is difficulty in distinguishing a pericardial friction rub
from a pleural friction rub, patients are asked to hold their breath;
a pericardial friction rub will continue.
The patient’s temperature is monitored frequently. Pericardi-
tis may cause an abrupt onset of fever in a patient who has been
afebrile.
Diagnosis
NURSING DIAGNOSES
Based on the assessment data, the major nursing diagnosis of the
patient may include:
• Acute pain related to inflammation of the pericardium
COLLABORATIVE PROBLEMS/
POTENTIAL COMPLICATIONS
Based on the assessment data, potential complications that may
develop include:
• Pericardial effusion
• Cardiac tamponade
Planning and Goals
The patient’s major goals may include relief of pain and absence
of complications.
Nursing Interventions
RELIEVING PAIN
Relief of pain is achieved by having the patient rest. Because sit-
ting upright and leaning forward is the posture that tends to re-
lieve pain, chair rest may be more comfortable. It is important to
instruct the patient to restrict activity until the pain subsides. As
the chest pain and friction rub abate, activities of daily living may
resume gradually. If the patient is receiving medications such as
analgesics, antibiotics, or corticosteroids for the pericarditis, his
or her responses are monitored and recorded. If chest pain and
friction rub recur, bed or chair rest resumes.
MONITORING AND MANAGING
POTENTIAL COMPLICATIONS
Pericardial Effusion. If the patient does not respond to medical
management, fluid may accumulate between the pericardial lin-
ings or in the sac. This condition is called pericardial effusion (see
Chap. 30). Fluid in the pericardial sac can constrict the myo-
cardium and interrupt its ability to pump. Cardiac output de-
clines with each contraction. Failure to identify and treat this
problem can lead to the development of cardiac tamponade and
the possibility of sudden death.
Cardiac Tamponade. The signs and symptoms of cardiac tam-
ponade begin with falling arterial pressure. Usually, the systolic
pressure falls while the diastolic pressure remains stable; hence,
the pulse pressure narrows. Heart sounds may progress from
sounding distant to being imperceptible. Neck vein distention
and other signs of rising central venous pressure are observed.
These signs and symptoms occur because, as the fluid-filled peri-
cardial sac compresses the myocardium, blood continues to return
to the heart from the periphery but cannot flow into the heart to
be pumped back into the circulation.
In such situations, the nurse notifies the physician immediately
and prepares to assist with pericardiocentesis (see Chap. 30). The
nurse stays with the patient and continues to assess and record signs
and symptoms while intervening to decrease the patient’s anxiety.
Evaluation
EXPECTED PATIENT OUTCOMES
Expected patient outcomes may include:
1. Is free of pain
a. Performs activities of daily living without pain, fatigue,
or shortness of breath
b. Temperature returns to normal range
c. Exhibits no pericardial friction rub
2. Absence of complications
a. Sustains blood pressure in normal range
b. Has heart sounds that are strong and can be auscultated
c. Shows absence of neck vein distention
? Critical Thinking Exercises
1. One of your neighbors has been diagnosed with mitral
regurgitation and does not understand why antibiotics need
to be taken before undergoing any dental work, including
routine checkups. How would you explain the rationale for
these instructions?
2. Plans for discharge from the hospital are being made for
a 26-year-old man with cardiomyopathy. His 24-year-old
wife says she is prepared to care for him at home; she expects
that he will be unable to participate extensively in his care.
Based on your knowledge about developmental tasks of 24-
to 26-year-olds, how would you explain the husband’s emo-
 Chapter 29 Management of Patients With Structural, Infectious, and Inflammatory Cardiac Disorders
tional and physical needs to the wife and the ways she can
address these needs, as well as her own? The cardiologist has
requested a consult with the transplant services; how will
your plan of care change?
3. A patient recovering from heart transplantation has a
short attention span, has a poor short-term memory, and can-
not sleep well. The family reports the patient is speaking more
rapidly than usual and is excessively excited and happy. The
surgeon states the high doses of steroids are most likely the
reason and expects the symptoms to diminish as the steroids
are tapered. Another patient who has undergone the same
surgical procedure cries frequently and has reported being
overwhelmed by the variety and schedule of medications.
The family has not been in to visit the patient for 2 days.
How would you explain the different reactions, and how
would your teaching strategies for these two patients differ?
4. You are caring for a man with pericarditis. His systolic
blood pressure begins to fall, and heart sounds cannot be
heard. Describe the actions you would take and why.
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