The nurse is caring for a client with acute pericarditis. Which clinical finding would require immediate intervention by the nurse?

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11ecbb05_c956_c49e_b433_5df4b40f3b5f_MD0009_00 Acute pericarditis is inflammation of the membranous sac (pericardium) surrounding the exterior of the heart, which can cause an increase in the amount of fluid in the pericardium (ie, pericardial effusion). Increased pericardial fluid places pressure on the heart, which impairs the heart's ability to contract and eject blood. This complication (ie, cardiac tamponade) is life-threatening without immediate intervention. When assessing clients with pericarditis, it is critical for the nurse to observe for signs of cardiac tamponade (eg, muffled or distant heart tones, hypotension, jugular venous distension) (Option B). Development of cardiac tamponade requires emergency pericardiocentesis (ie, needle insertion into the pericardium to remove fluid) to prevent cardiac arrest. (Option A) In acute pericarditis, the inflamed pericardium rubs against the heart, causing pain that often worsens with deep breathing or when positioned supine. The client should be placed in the Fowler position with a support (eg, bedside table) to lean on for comfort. (Option C) ST-segment elevation in almost all ECG leads is a characteristic of acute pericarditis that typically resolves as pericardial inflammation decreases. This is in contrast to acute myocardial infarction, in which ST-segment elevation is seen in only localized leads (depending on which vessel is occluded). (Option D) Pericardial friction rub is an expected finding with acute pericarditis that occurs from the layers of the pericardium rubbing together to create a characteristic high-pitched, leathery, and grating sound. Educational objective: Nurses caring for clients with pericarditis should monitor for, and immediately report, signs of cardiac tamponade (eg, jugular venous distension, distant heart sounds, hypotension), a life-threatening complication occurring from increased pericardial fluid volume.

The Nurse Is Caring for a Client with Acute Pericarditis