Medical Surgical Pericarditis #1

Question

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?

Answers

  1. Risk for falls related to weakness, pain, and dizziness
    • Rationale:

      This answer is not correct because while risk for falls may be a part of the plan of care, the client’s pain affects the heart and oxygenation. Pericarditis causes severe pain with rapid onset that worsens with breathing, coughing, and/or changing positions. Leaning forward can help alleviate the pain. Such pain prevents the 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.

  2. Acute pain related to inflammation of the pericardium
    • Rationale:

      This answer is correct because pericarditis is the inflammation of the membranous sac that surrounds the heart. Pericarditis causes severe pain with rapid onset that worsens with breathing, coughing, and/or changing positions. Such pain prevents the 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.

  3. Imbalanced nutrition: less than body requirements related to decreased intake, nausea and anorexia
    • Rationale:

      This answer is not correct because while risk for falls may be a part of the plan of care, the client’s pain affects the heart and oxygenation. Pericarditis causes severe pain with rapid onset that worsens with breathing, coughing, and/or changing positions. Such pain prevents the 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.

  4. Activity intolerance related to fatigue and physical weakness
    • Rationale:

      This answer is not correct because while risk for falls may be a part of the plan of care, the client’s pain affects the heart and oxygenation. Pericarditis causes severe pain with rapid onset that worsens with breathing, coughing, and/or changing positions. Such pain prevents the 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.

Overview

Pain associated with pericarditis is a priority finding to be addressed by the nurse. Pain can prevent the ability to help with respiratory efforts in the client.

Explanation

Learning Outcomes

Pericarditis is the inflammation of the membranous sac that surrounds the heart. There is acute pain associated with the inflammation of the pericardium. Pericarditis causes severe pain with rapid onset that worsens with breathing, coughing, and/or changing positions. Leaning forward can help alleviate the pain. Such pain prevents the 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. Another very common finding with pericarditis is a pleural friction rub. A pleural friction rub has a scratching, grating sound similar to leather rubbing against leather. Auscultation is best heard with the diaphragm of the stethoscope over the left lower sternal edge or apex during end expiration while the client is sitting up and leaning forward.

Test Taking Tip

Pericarditis: Think “P” for Pain from “-itis” (inflammation) and the “C” in carditis is for Compression of the heart from fluid.

Video Rationale