Medical Surgical Cardiac Tamponade #2

Question

The nurse expects which priority intervention to occur when a cardiac tamponade occurs?

Answers

  1. Paracentesis
    • Rationale:

      This answer is not correct because pericardiocentesis (removal of the excessive fluid in the pericardium), not paracentesis (removal of fluid from the abdominal cavity) is the appropriate treatment for cardiac tamponade. Cardiac output will be restored when the pressure on the heart from the fluid is removed.

  2. Defibrillation
    • Rationale:

      This answer is not correct because defibrillation is not the proper treatment for the client yet. If the fluid is removed from the pericardium by means of pericardiocentesis, then the client should not need defibrillation.

  3. Pericardiocentesis
    • Rationale:

      This answer is correct because immediate pericardiocentesis (removal of the excessive fluid in the pericardium) is the treatment for cardiac tamponade since there is then no cardiac output until the pressure of the fluid is removed. Cardiac tamponade is a serious medical emergency in which blood or other fluids fill the pericardial space (the sac that surrounds the heart). This extra fluid places increased pressure on the heart to the extent that the ventricles cannot fill and contract.

  4. Coronary bypass graft surgery
    • Rationale:

      This answer is not correct because coronary bypass graft surgery is not an appropriate intervention because the client has excessive fluid placing pressure on the heart, not a blockage of a coronary artery. This extra fluid places increased pressure on the heart to the extent that the ventricles cannot fill and contract. Therefore, immediate pericardiocentesis (removal of the excessive fluid in the pericardium) is the treatment for cardiac tamponade since there is then no cardiac output until the pressure of the fluid is removed.

Overview

Immediate pericardiocentesis (removal of the excessive fluid in the pericardium) is the treatment for cardiac tamponade.

Explanation

Learning Outcomes

Cardiac tamponade is a serious medical emergency in which blood or other fluids fill the pericardial space (the sac that surrounds the heart). This extra fluid places increased pressure on the heart to the extent that the ventricles cannot fill and contract. There is then no cardiac output until the pressure of the fluid is removed. Immediate pericardiocentesis (removal of the excessive fluid in the pericardium) is the treatment. The classic clinical manifestations of cardiac tamponade are considered hypotension, jugular vein distention (JVD), and muffled heart tones. Other symptoms that occur include tachypnea, tachycardia, restlessness, shortness of breath, weakness, anxiety, chest pain, loss of consciousness as cardiac output decreases.

Test Taking Tip

Like a tampon puts pressure to stop bleeding, a cardiac tamponade creates pressure on the heart due to bleeding or fluid that has leaked into the pericardium.

Video Rationale