Week 8: Chp 30: Pericarditis Flashcards
What is pericarditis?
inflammation of the pericardium
Epidemiology
- not related to ischemia
- 80% of cases are idiopathic (unknown etiology) or are presumed to occur after viral infection
- acute pericarditis is common following MI
- low mortality rate
How can pericarditis be categorized?
-infectious (viral, bacterial, fungal, parasitic)
-noninfectious (autoimmune, neoplastic, metabolic, trauma, and drug related)
idiopathic
>acute, chronic, or recurrent
Pathophysiology of Pericarditis
When the pericardium becomes inflamed
- the heart is surrounded by two-layered pericardium, which protects the heart, reduces friction with surrounding structure, and helps to determine chamber size and pressure
- the tough, fibrous outer wall is the parietal pericardium
- the inner is the visceral pericardium, or epicardium
- the space between the pericardium and the epicardium contains 20 to 60 mL of pericardial fluid; the fluid acts as a lubricant to prevent friction between the 2 layers
- When the pericardium becomes inflamed, it is termed pericarditis
The heart is surrounded by what?
a two-layered pericardium
What does the pericardium do?
protect the heart, reduces friction with surrounding structures, and helps determine chamber size and pressure
What are the two-layers of the pericardium?
- Parietal pericardium: the tough, fibrous outer wall
- Visceral pericardium/ epicardium: inner wall
What is between the parietal pericardium and visceral pericardium/epicardium?
pericardial fluid; acts as a lubricant to prevent friction between the two layers
Clinical Manifestations
- pleuritic chest pain (most common); tends to be relieved by sitting up and leaning forward
- auscultation of friction rub (scratchy sound heard with each heartbeat)
- new or worsening pericardial effusion
- ECG changes: diffuse ST-segment elevations or PR depressions
- fever
Tests For Diagnosis
- ECG
- Chest x-rays
- echocardiogram (transthoracic or transesophageal)
- cardiac CT scan
- MRI
Diagnosis: Electrocardiogram (hallmark changes)
hallmark ECG changes include widespread ST-segment elevation or PR segment depression
Diagnosis: Chest x-ray
the finding of cardiomegaly (enlarged heart) and clear lung fields may indicate pericardial effusion (fluid build up in the pericardial sac) and might be supportive of pericarditis
Pericardial Effusion
fluid buildup in the pericardial sac
- may be found on a chest x-ray
- might be supportive of pericarditis
- might also be evident on an echocardiogram, CT scan, or MRI
- complication of pericarditis
Laboratory Tests
- Serial cardiac biomarkers to rule out MI
- positive blood cultures
- a CBC with a high WBC count
- positive inflammatory markers such a C-reactive protein or
- sedimentation rates may indicate presence of infection or inflammation, leading to the diagnosis of pericarditis when combined with the clinical manifestations
Medication Goals
alleviate pain and stop the inflammatory process
Medications Used
- Aspirin and other NSAIDSs are indicated
- Colchicine may be used as an additional anti-inflammatory with acetylsalicylic acid (ASA) or NSAIDs
- If pain or inflammation is not relieved by ASA or NSAID, corticosteroids may b used
- antimicrobial therapy might be used if bacterial pericarditis
Complications
- pericardial effusion (accumulation of fluid in the pericardial space exceeding the typical 20 to 60 mL)
- pericardial fluid may accumulate slowly (ie. neoplastic), allowing pericardium to stretch to accommodate the increased volume; clinical symptoms progress; rapidly growing effusions overwhelm the stretching capacity of the pericardium, resulting in acute decompensation; if not treated emergently, the increased fluid volume within the pericardial space can exert pressure on the heart resulting in cardiac tamponade
- Cardiac tamponade
Pericardial effusion is diagnosed by
chest x-ray, echocardiography, and ECG
Depending on the volume of excess fluid and clinical presentations what may be indicated?
pericardiocetesis
Pericardiocentesis
this may be indicated depending on the volume and clinical manifestations from excess fluid
-ultrasound guides needle insertion through the chest wall to aspirate the excess fluid
Complication: Cardiac Tamponade
the excessive fluid in the pericardial sac compresses the cardiac structures and dramatically decreases cardiac output
- common signs: dyspnea, tachycardia, pulsus paradoxus, JVD, an enlarged heart, and muffled heart tones
- Beck’s triad is the classic finding of hypotension, muffled heart sounds, and JVD (emergent pericardiocentesis)
Pulsus Paradoxus
abnormal drop in systolic BP during inspiration
Surgical Management of pericardial effusions and cardiac tamponade
-pericardial window; in which a window or fistula is created to drain excess fluid from the pericardial space
Nursing Management: Assessment and Analysis
- the major clinical manifestations of pericarditis is pain due to friction between the inflamed layers of the heart that occurs with movement
- Excessive accumulation of fluid, or pericardial effusion, can result in acute decompensation due to the increased pressure around the heart limiting ventricular filling and contraction, resulting in decreased cardiac output
The major clinical manifestations of pericarditis is pain due to what?
friction between the inflamed layers of the heart that occurs with movement
Excessive accumulation of fluid, or pericardial effusion, can result in acute decompensation due to what?
the increased pressure around the heart limiting ventricular filling and contraction, resulting in decreased CO
Nursing Diagnosis
- chest pain r/t swelling and inflammation secondary to pericarditis
- risk for decreased cardiac output r/t cardiac structure compression
Nursing Interventions: Assessment
- vital signs
- pain
- auscultate heart sounds
- ECG
Assessment: Vital Signs
hypotension, tachycardia, tachypnea, and pulsus paradoxus are indicative of cardiac tamponade, which is due to an excessive or sudden buildup of pericardial effusion
-fever is indicative of an ongoing infection
Assessment: Pain
chest pain that is relieved by sitting up and leaning forward distinguishes pericarditis pain from the pain associated with an MI
Assessment: Auscultate Heart Sounds
a friction rub is a common finding of pericarditis
-muffled heart tones may indicate pericardial effusion or cardiac tamponade
Assessment: ECG
-ST-elevation or PR depression in all or most leads can be associated with pericarditis
Friction rub
scratchy sound heard with each heart beat
- a result of the friction between the inflamed layers of the pericardium when the heart moves within the pericardial sac
- best heard over the left sternal border at the end of expiration with the patient leaning forward
- it produced a high-pitched, scratchy noise and is muffled when excess fluid is present
How is the chest pain relieved?
by sitting up and leaning forward
Nursing Interventions: Actions
- keep the head of the bed elevated
- administer NSAIDs or ASA and colchicine medications as prescribed
- provide emotional support
Nursing Action: Keep the head of the bed elevated
pericardial effusion exerts pressure on the surrounding organs resulting in orthopnea (SOB when lying down) and dyspnea
- raising the head of the bed relieves SOB
- pain is also relieved by sitting in the upright position
Nursing Actions: Administer NSAIDs or ASA and colchicine medications as prescribed
pain relating to pericarditis is associated with inflammation, so control is largely managed with anti-inflammatories
-steroids are added if necessary
Nursing Actions: Provide emotional support
anxiety can occur because of the fear that the pain is from a heart attack
Teaching
- avoid strenuous activity until symptoms resolve or laboratory values return to normal
- distinguish between the pain of pericarditis and heart attack
Teaching: Avoid strenuous activity until symptoms resolve or lab values return to normal
activity restrictions may reduce the risk of sudden cardiac death, which is rare but has been reported
Teaching: distinguish between the pain of pericarditis vs heart attack
ensures patient will seek help appropriately
Primary goal of care
pain relief
-early recognition and management of pericardial effusions are also important factors in the care of these patients
Well-Managed patient
- free from pain, SOB and indicators of cardiac tamponade
- Ensuring the patient and family is knowledgeable about the signs and treatment of the disease as well as indicators of pericardial effusion is necessary to avoid the negative consequences associated with cardiac tamponade
