Activity 11 Cardiac Tamponade NCP

Student Name: Aljean Cloe Q.
Corpuz Level: III Group: O
NURSING CARE PLAN
Make 1 Nursing Care Plan with each cancer emergency mentioned in the lecture
presentation with the corresponding Nursing Diagnosis. (make sure to do this right as this
will help you during the final oral revalida. You may find these in medical surgical nursing
books.
There are ebooks in the RESOURCES FOLDER of our MOLE. You may also use other
sources)
Nursing Diagnosis: Decreased Cardiac output r/t fluid in pericardial sac
Expected Outcomes: Cardiac Pump Effectiveness as evidenced by the following indicators:
Blood pressure/Heart rate/Cardiac index/Ejection fraction/Activity tolerance/Peripheral pulses/Neck

vein distention not present/Heart rhythm/Heart sounds/Angina not present/ Peripheral edema not
present/Pulmonary edema not present.
Signs and Symptoms:

 Restlessness
 Agitation
 Weakness
 Anorexia
 Chest discomfort
 Shortness of breath
 Feeling of impending doom
 Poor tissue perfusion
Intervention Rationale Evaluation

INDEPENDENT INDEPENDENT
1. Monitor orthostatic 1. These interventions
blood pressures and assess for fluid volume Short term:
daily weights status  Client will be able to
2. Continuously monitor 2. Chest radiography, demonstrate adequate
ECG for dysrhythmia echocardiography, and cardiac output as
formation, which may electrocardiogram are evidenced by blood
result of myocardial recommended in the pressure, pulse rate
ischemia secondary to initial assessment of and rhythm within
epicardial coronary HF. normal parameters.
artery compression. Long term
3. Place client in semi- 3. Elevating the head of
 Client will remain free
Fowler’s or high the bed and legs in
of side effects from the
Fowler’s position with down position may
medications used to
legs down or in a decrease the work of
achieve adequate
position of comfort breathing and may
cardiac output
also decrease venous
return and preload.  Client will be able to
4. Provide a restful 4. Reducing stressors explain actions and
environment by decreases cardiac precautions to prevent
minimizing controllable workload and oxygen primary or secondary
stressors and demand. cardiac disease
unnecessary
disturbances.
5. Check blood pressure, 5. It is important that the
pulse, and condition nurse evaluate how
before administering well the client is
cardiac medications tolerating current
such as medications before
angiotensinconverting administering cardiac
enzyme inhibitors, medications; do not
angiotensin receptor hold medications
blockers, digoxin, and without health care
beta-blockers. Notify provider input. The
health care provider if health care provider
heart rate or blood may decide to have
pressure is low before medications
holding medications. administered even
though the blood
pressure or pulse rate
has lowered.
6. Observe for and report 6. Chest pain/discomfort
chest pain or may indicate an
discomfort; note inadequate blood
location, radiation, supply to the heart,
severity, quality, which can further
duration, and compromise cardiac
associated output
manifestations such as
nausea, indigestion, or
diaphoresis; also note
precipitating and
relieving factors.
7. Closely monitor intake 7. Decreased cardiac
and output (I&O) output results in
decreased perfusion of
the kidneys, with a
resulting decrease in
urine output
DEPENDENT DEPENDENT
8. Provide supplemental 8. Supplemental oxygen
oxygen as ordered. increases oxygen
availability to the
myocardium and can
relieve symptoms of
hypoxemia.
COLLABORATIVE
COLLABORATIVE 9. Excess sodium can
9. Provide referral to contribute to elevation
dietician. Serve small, of blood pressure,
frequent, sodium- renal impairment,
restricted, low ventricular
saturated fat meals. hypertrophy, diastolic
dysfunction, and
fibrosis of coronary
arteries
10. Cardiac rehabilitation
10. Refer to a cardiac can improve quality of
rehabilitation program life and functional
for education and capacity, and
monitored exercise decrease mortality

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Student Name: Aljean Cloe Q.

Corpuz Level: III Group: O

NURSING CARE PLAN

Nursing Diagnosis: Decreased Cardiac output r/t fluid in pericardial sac

Expected Outcomes: Cardiac Pump Effectiveness as evidenced by the following indicators:

Blood pressure/Heart rate/Cardiac index/Ejection fraction/Activity tolerance/Peripheral pulses/Neck

Signs and Symptoms:

Intervention Rationale Evaluation

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