Cardiac Question #48
The nurse is caring for a client admitted for acute pericarditis. Which nursing diagnosis should take priority during the first 24 hours of nursing care?
- Risk for falls related to weakness, pain, and dizziness
- Acute pain related to inflammation of the pericardium
- Imbalanced nutrition: less than body requirements related to decreased intake, nausea and anorexia
- Activity intolerance related to fatigue and physical weakness
Relief of chest pain is one of the prioritized nursing diagnoses. Pericarditis causes severe pain with rapid onset that worsens with breathing, coughing, and/or changing positions. Such pain prevents ability to help respiratory efforts. It worsens as excessive accumulation of fluid in the pericardial sac occurs. The result is decreased stroke volume and compression of the heart. While risk for falls, activity intolerance, and imbalanced nutrition may be a part of the plan of care, pain affects the heart and oxygenation.
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