A client with suspected moderate to large pericardial effusion is admitted for monitoring. The nurse performs a head-to-toe assessment. Which of these findings indicate likely cardiac tamponade and require immediate intervention? Select all that apply.

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11ecbb05_c947_5b42_b433_6f92aff88ce8_MD0009_00 Pericardial effusion is a buildup of fluid in the pericardium. Tamponade, a serious complication of pericardial effusion, develops as the effusion increases in volume and results in compression of the heart. The heart struggles to contract effectively against the fluid, and cardiac output can decrease drastically. This life-threatening complication requires an emergency pericardiocentesis (a needle inserted into the pericardial sac to remove fluid). Signs and symptoms of cardiac tamponade include: Hypotension with narrowed pulse pressure (Option A) Muffled or distant heart tones (Option D) Jugular venous distension (Option E) Pulsus paradoxus Dyspnea, tachypnea Tachycardia (Option B) Bounding pulses may be present during fluid overload or hypertension. They may also be present with anxiety or fever. The client with possible tamponade will have evidence of decreased cardiac output and is more likely to have weak, thready pulses. (Option C) Decreased breath sounds on the left side are not specific to the development of cardiac tamponade. Decreased breath sounds could indicate conditions such as atelectasis, pleural effusion, or pneumothorax. Educational objective: The client with a moderate to large pericardial effusion is at risk for the development of cardiac tamponade. Signs and symptoms of tamponade include muffled or distant heart tones, narrowed pulse pressure, jugular venous distension, pulsus paradoxus, dyspnea, tachypnea, and tachycardia. The nurse should report these findings to the health care provider immediately and prepare for a pericardiocentesis.

A Client with Suspected Moderate to Large Pericardial Effusion Is