Nursing Care Plan (NCP) for Pericarditis

Understanding Pericarditis:
- Define pericarditis and its etiology, emphasizing inflammation of the pericardial sac.
- Differentiate between acute and chronic pericarditis, highlighting potential complications.
Recognition of Clinical Manifestations:
- Identify common signs and symptoms of pericarditis, such as chest pain, pericardial friction rub, and ECG changes.
- Recognize the variations in presentation and potential complications.
Diagnostic Procedures:
- Understand diagnostic procedures used to confirm pericarditis, including electrocardiogram (ECG), echocardiography, and blood tests (e.g., markers of inflammation).
Pharmacological Interventions:
- Explore the pharmacological treatments commonly used in managing pericarditis, such as nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, and corticosteroids.
Understand the rationale behind medication choices and potential side effects.
- Monitoring and Complication Prevention:
- Comprehend the importance of monitoring vital signs, ECG changes, and fluid balance in pericarditis management.
- Learn strategies to prevent complications, such as pericardial effusion, cardiac tamponade, and constrictive pericarditis.

Pathophysiology of Pericarditis

Inflammation of the Pericardial Sac:
- Pericarditis is characterized by inflammation of the pericardium, the double-layered sac surrounding the heart.
Pericardial Friction Rub:
- Inflammatory changes within the pericardial layers lead to the development of a pericardial friction rub.
- The friction rub is an audible, scratchy or grating sound heard on auscultation, resulting from the rubbing together of inflamed pericardial surfaces during the cardiac cycle.
Increased Pericardial Fluid:
- In response to inflammation, the pericardial membranes may produce an excess of pericardial fluid.
- Accumulation of fluid can lead to pericardial effusion, potentially causing compression of the heart and impairing cardiac function.
Myocardial Irritation and ECG Changes:
- Inflammation of the pericardium can irritate the adjacent myocardium.
- Myocardial irritation manifests as ECG changes, including ST-segment elevation, PR-segment depression, or diffuse T-wave changes, which are characteristic findings in pericarditis.
Potential Complications:
- If left untreated, pericarditis can progress to complications such as pericardial effusion, cardiac tamponade, or constrictive pericarditis.
- Pericardial effusion occurs when excess fluid accumulates in the pericardial sac, while cardiac tamponade involves compression of the heart due to the accumulation of fluid, leading to decreased cardiac output.

Etiology of Nursing Care Plan (NCP) for Pericarditis

Infections:
- Viral infections are a common cause of pericarditis, with viruses such as Coxsackievirus, echovirus, and influenza frequently implicated.
- Bacterial or fungal infections can also lead to pericarditis, especially in individuals with compromised immune systems.
Autoimmune and Inflammatory Disorders:
- Autoimmune conditions, including rheumatoid arthritis and systemic lupus erythematosus (SLE), can contribute to pericarditis.
- Inflammatory disorders like rheumatic fever and inflammatory bowel disease may also be associated with pericardial inflammation.
Myocardial Infarction (Dressler Syndrome):
- Pericarditis can develop as a complication following a myocardial infarction, a condition known as Dressler syndrome.
- Inflammation may occur in response to the release of myocardial antigens, leading to an autoimmune response affecting the pericardium.
Uremia:
- Pericarditis can result from uremic toxins accumulating in the blood, particularly in individuals with advanced kidney disease.
- Uremic pericarditis is a type of pericarditis associated with kidney failure.
Idiopathic (Unknown Cause):
- In a significant number of cases, the specific cause of pericarditis remains unknown.
- Idiopathic pericarditis may be diagnosed when no clear infectious, autoimmune, or other identifiable cause is found.
Inflammation can result from various causes, including infections, autoimmune disorders, myocardial infarction, or idiopathic factors.

Desired Outcomes for Pericarditis

Resolution of Pericardial Inflammation:
- Achieve the resolution of pericardial inflammation, leading to the restoration of normal pericardial function.
- Monitor clinical signs and symptoms, such as chest pain and pericardial friction rub, for improvement.
Relief of Symptoms:
- Alleviate symptoms associated with pericarditis, including chest pain, dyspnea, and fatigue.
- Utilize pain management strategies and anti-inflammatory medications to enhance patient comfort.
Prevention of Complications:
- Prevent or promptly address complications such as pericardial effusion, cardiac tamponade, or constrictive pericarditis.
- Regularly assess for signs of complications, such as changes in hemodynamic stability or increasing pericardial fluid.
Normalization of ECG Changes:
- Normalize ECG findings associated with pericarditis, including resolution of ST-segment elevation, PR-segment depression, and T-wave changes.
- Monitoring ECG changes helps gauge the progress of treatment and the resolution of cardiac irritation.
Identification and Management of Underlying Cause:
- Identify and address the underlying cause of pericarditis, whether it is infectious, autoimmune, or related to another condition.
- Tailor treatment strategies based on the specific etiology to prevent recurrence.

Pericarditis Nursing Care Plan

Subjective Data:

Chest Pain
- Aggravated by breathing, coughing, swallowing
- Worse when supine
Symptoms of Heart Failure

Objective Data:

↑ Temperature
↑ WBC
Signs of Heart Failure
ST-Elevation possible
↓ SpO2
S/S Cardiac Tamponade
- Muffled heart sounds
- Narrow Pulse Pressure
- Pulsus paradoxus
- JVD with clear lungs
- ↓ Cardiac Output

Nursing Assessment of Pericarditis

Chest Pain Assessment:
- Conduct a thorough assessment of chest pain characteristics, including location, intensity, quality, and factors that exacerbate or alleviate the pain.
- Use a pain scale to quantify and monitor changes in chest pain over time.
Cardiorespiratory Assessment:
- Monitor vital signs regularly, paying close attention to heart rate, blood pressure, and respiratory rate.
- Assess for signs of cardiac compromise, such as changes in heart sounds, presence of a pericardial friction rub, and respiratory distress.
Electrocardiogram (ECG) Monitoring:
- Perform continuous ECG monitoring to identify characteristic changes associated with pericarditis, such as ST-segment elevation, PR-segment depression, or T-wave changes.
- Regularly assess for any dynamic ECG changes indicating evolving pericarditis.
Pericardial Friction Rub:
- Auscultate for the presence of a pericardial friction rub, a key clinical sign of pericarditis.
- Note the timing (systolic, diastolic, or throughout the cardiac cycle) and location of the friction rub.
Respiratory Assessment:
- Assess respiratory status, including the presence of dyspnea, tachypnea, or signs of respiratory distress.
- Evaluate oxygen saturation levels and the need for supplemental oxygen.
Fluid Status Assessment:
- Monitor fluid balance, assessing for signs of fluid retention or dehydration.
- Evaluate peripheral edema, jugular venous distention, and lung sounds for signs of congestion.
Pain Management Assessment:
- Evaluate the effectiveness of pain management interventions, including the administration of prescribed analgesics and positioning to relieve discomfort.
- Encourage the patient to report changes in pain intensity or characteristics.
Psychosocial Assessment:
- Assess the patient’s emotional well-being and response to the diagnosis and symptoms of pericarditis.
- Address anxiety or concerns about the condition and its impact on daily life.

Nursing Interventions and Rationales

Assess Heart and Lung Sounds

May hear a pericardial friction rub, muffled heart sounds, or extra sounds because of the pressure being placed on the heart. It’s possible but unlikely that you will hear fluid in the lungs – in cardiac tamponade, the lungs will be clear.

Assess and Address Oral Hygiene

There is a significant connection between oral health and pericarditis. Bacteria can travel to the heart easily from the oral cavity. Patients should brush their teeth twice daily to prevent complications.

Administer IV Antibiotics

If the source is bacterial, IV antibiotics will be required to treat the infection. Be sure to obtain blood cultures before initiating antibiotics. If the source is viral – providers may order anti-inflammatory medication since antibiotics aren’t effective. If the virus is known and susceptible, an antiviral medication could be used.

Perform 3-5 lead ECG monitoring and/or 12-lead ECG

Pericarditis could cause arrhythmias or ST-elevation as the fluid puts pressure on the heart. Cardiac tamponade is a risk – in which case we’ll see the QRS amplitude decrease with inspiration.

Assess and Manage Pain

Patients will have significant chest pain that is worse with breathing or when supine. Perform OLDCARTS pain assessment and administer pain medication as ordered. Positioning the patient in High-Fowler’s position can also relieve pressure on the heart and be more comfortable for the patient.

Assess for s/s Cardiac Tamponade

Assess for Beck’s Triad – JVD, ↓ BP, muffled heart sounds. May also see Pulsus paradoxus and narrowing pulse pressures. This is a medical emergency and needs to be treated as such.

Prepare patient for emergent pericardiocentesis

A physician will insert a large, long needle into the pericardial sac, using ultrasound as a guide, to drain off the fluid that is collecting around the heart. This will allow the heart to beat more freely and should improve cardiac output rapidly.

Educate patient on s/s infection

Pericarditis is an infectious process; therefore, infection control is imperative. They need to be taught hand hygiene as well as other infection precautions. They should also be taught s/s of infection to report to their provider.

Educate the patient to inform other providers before procedures
- May need prophylactic antibiotics
- No dental procedures for at least 6 months

Because the patient is at high risk for recurrence and complications, they must notify other providers of their history of pericarditis. They may require prophylactic antibiotics before any invasive procedures, and they should avoid dental procedures for at least 6 months after their hospitalization.

Nursing Evaluation of Managing Pericarditis

Pain Relief and Comfort:
- Assess the effectiveness of pain management interventions, including the administration of analgesics and positioning measures.
- Monitor changes in the patient’s reported pain levels and overall comfort.
Resolution of Inflammation:
- Evaluate the response to anti-inflammatory medications by assessing for a reduction in pericardial inflammation.
- Monitor for changes in clinical signs and symptoms, such as resolution of pericardial friction rub and normalization of ECG findings.
Complications Monitoring:
- Continuously monitor for signs of complications, including pericardial effusion, cardiac tamponade, or constrictive pericarditis.
- Collaborate with the healthcare team to address any identified complications promptly.
Patient Education Understanding:
- Assess the patient’s understanding of pericarditis, its treatment plan, and the importance of lifestyle modifications.
- Clarify any misconceptions and provide additional education as needed.
Psychosocial Well-being:
- Evaluate the patient’s psychosocial well-being and emotional response to the diagnosis and treatment of pericarditis.
- Provide ongoing support and resources for coping with the impact of the condition on daily life.

References

https://www.mayoclinic.org/diseases-conditions/pericarditis/symptoms-causes/syc-20352510

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Transcript

Today we are going to be talking about pericarditis. Pericarditis is the inflammation of the pericardium, the area around the heart. Pericarditis could be caused by either an infectious source, so which could be viral, bacterial, or fungal, or it can be caused by an MI. Some of the things we want to think about as nurses when we are taking care of these patients are we want to think about performing a 12 lead EKG. We want to do a good assessment, listening to the heart sounds, and we want to manage their pain. This thing is very painful, our desired outcome. We want to treat the cause and remove the source of infection. If it’s caused by an infection while preserving the cardiac output and preventing any other major or minor complications.

So, you have inflammation inside of your pericardium. So, what are some things that you think we’d need to, uh, look out for? What do you think the patient’s going to tell us? Well, first number one is chest pain. These patients are in pain, so it’s aggravated by breathing, coughing, and swallowing. So it’s not normal chest pain. When you’re gonna think about, um, like when you have a heart attack, it’s going to be exacerbated by coughing and breathing. We also want to think about pain. That’s worse when they’re supine. So when they’re lying flat on their back, that pain is worse. That’s why you oftentimes see those pericarditis patients leaning forward to get relief. And also you’ll see some symptoms of heart failure, you know, fluid overload, shortness of breath, those types of things, some signs that we’ll see as a nurse, some objective signs that we’ll see increased temperature fever. We’re going to see increased white blood cells. That’s going to be on the labs again, signs of heart failure. We may see some ST elevation on the EKG that we perform. We’re going to see decreased o2 SATs.

We’re going to see signs and symptoms of cardiac tamponade. So that’s actually very, uh, specialized, um, condition, the cardiac tamponade, not, and not just run over those really quickly. The fact that some of the cardiac tamponade not, ER, muffled heart sounds narrow, pulse pressure, uh, juggler, venous distension, and also a decreased cardiac output. So nursing intervention, obviously with ad PI, we want to focus on assessing the person. We want to assess the heart, assess the lungs. You may hear something, what we call pericardial friction rub. And that’s just a heart sound that we’re going to hear when we’re auscultating, you may hear muffled heart sounds, or you may hear extra sounds because of all the extra pressure from the inflammation.

We also want to perform that, uh, that EKG. So, we want to take a look at the heart from an electrical standpoint. Pericarditis is known for causing any type of arrhythmias and ST elevation has fluid builds up so, we want to focus on that as well. We want to manage the pain because the pain is out of this world for these patients, okay. Patients are going to have significant chest pain that is worse when breathing, and also when they’re supine. Remember old carts, we want to assess the character. We want to assess the location. What makes it better? What makes it worse? We want to do a good pain assessment and administer any type of pain medication or anti-inflammatories as necessary. And that’s order again. We want to check for cardiac tamponade. We want to assess Beck’s triad. And that is the JVD the juggler vein distension, decreased BP, and muffled heart sounds. That is Beck’s Triad. We want to prepare the patient for an emergent pericardiocentesis. I know that’s a long word, but all we’re saying is we want to go in and drain some of the fluid that’s around the heart, and that’s, um, will allow the heart to beat more freely and it will improve cardiac output rapidly as soon as the procedure’s done. We want to educate the patient on the signs and symptoms of infection. So we want to make sure that the patient has no dental work, uh, for at least six months because the patient is at high risk for a reoccurrence. We want to make sure that they notify providers, that they don’t have a history of pericarditis. Very important. The next thing I want to show you is what the EKG looks like when a patient presents with pericarditis.

So as you see here, there is ST Elevation here, here, here, this ST elevation all over. And the thing that makes this unique is because with a heart attack or am I, you will see ST elevation, but typically in one lead pericarditis, because of the inflammatory process, the EKG is going to show inflammation and multiple leads. So that’s something that will help rule out whether it’s a heart attack or MI. Some key points, pathophysiology. Pericarditis is an inflammation of the heart is caused by the bacterial virus, or am I the subjective things that we want to focus on? Chest pain, pain that is worse with supine, some symptoms of heart failure, the things that we want to assess for as nurses, or we want to assess for fever. There may be some ST elevation on that EKG. And also they’re going to have some decreased o2 Sats.

We want to do a good cardiac assessment, 12 lead EKG. We want to take a listen. We want to auscultate, and we want to keep track of those vital signs. We may see or hear those muffled heart tones or pericardial friction rubs. When we listen, pain management is, is very important. We want to do frequent pain assessments, at least every two hours. And we want to administer, uh, anti-inflammatories uh, with the frequency as ordered by the doctor. I know that this was a lot of information, but I know you guys are going to do so well on it. We love you guys go out and be your best self today. And as always happy nursing.