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LEARNING
OBJECTIVE
LEARNING
QUESTION
LEARNING ISSUE SOURCES/MATERIALS EVIDENCES CRITERIA FOR EVALUATION
KNOWLEDGE KNOWLEDGE KNOWLEDGE
- To identify the diagnosis of the patient. 1. What is the diagnosis of the patient? To meet the objectives and answers of the learning questions, the RLE group members
must do the following:
● Use of evidenced-bas ed learning with journals and articles. ● Use of books and modules as a reference. ● Usage of the North American Nursing Diagnosis Association (NANDA) as a guide. Spangler, S. (2021, October 17). What is the significance of a pericardial friction rub in the evaluation of acute pericarditis? Medscape. Retrieved November 29, 2021, from https://www.medscape.co m/answers/156951- 1/what-is-the-significance -of-a-pericardial-friction-r ub-in-the-evaluation-of-ac ute-pericarditis#:%7E:text =A%20pericardial%20fric tion%20rub%20is,in%20a pproximately%2050% %20of%20cases.
1. DIAGNOSIS OF THE PATIENT
The patient may be suffering from pericarditis as the presence of pericardial friction rub is considered a pathognomonic sign of the disease. The patient’s other clinical manifestations such as dyspnea, fatigue, fever, chest pain, and tachycardia all support the diagnosis of pericarditis. In addition, recurrent throat infections and tooth infections from dental procedures, although rare, may cause pericarditis due to pathogen (commonly bacteria such as streptococcus) travelling in the blood and reaching the heart to cause pericarditis. The patient’s recent heart attack may have also contributed to the diagnosis of pericarditis as myocardial infarction damages and inflames the tissues of the heart which can cause pericarditis.
EVALUATION
Tutor to Student ● RLE Clinical Instructors in Care of Clients with problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations, Acute and Chronic. Student to Tutor ● Nursing students studying Care of Clients with problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations, Acute and Chronic through brainstorming. Student Self & Peer ● Group members that are studying Care of Clients with problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations,Acute and Chronic
- To define Pericarditis and its pathophysiolog y. 2. What is the definition of Pericarditis and its specific pathophysiol ogy? American Heart Association. (2021b, April 8). What is Pericarditis? Retrieved November 29, 2021, from https://www.heart.org/en/ health-topics/pericarditis/ what-is-pericarditis#:%7E :text=Pericarditis%20is% 20inflammation%20of%
2. DEFINITION AND PATHOPHYSIOLOGY OF
PERICARDITIS
Pericarditis can be defined as the inflammation of the pericardium, which is a sac with two thin layers that surrounds, protects, and supports the heart. A little quantity of fluid separates the layers, causing less friction while the heart beats. In pericarditis, fluid moves from the capillaries to the area between the pericardial sac and the heart. This fluid can be
through sharing and brainstorming CRITERIA ● Written Output ● Active participation ● Oral Presentation ● Reporting DEADLINE November 29, 2021 at 5pm 0the,them%20as%20the %20heart%20beats. serous (caused by heart failure), purulent (caused by infections), serosanguineous (caused by neoplasms or uremia), or hemorrhagic (resulting from aneurysms or trauma). A pericardial effusion occurs when fluid accumulates in the pericardial cavity. This disease can lead to life-threatening cardiac tamponade. As the pericardial tissue swells, the enlarged pericardial tissue scrapes against the swollen cardiac tissue, causing friction. Frequent or protracted bouts of pericarditis or Chronic Pericarditis may also result in pericardium thickening and reduced flexibility, or scarring may merge the visceral and parietal pericardium. These disorders limit the ability of the heart to fill with blood (constrictive pericarditis). The pericardium may become calcified, limiting ventricular expansion during ventricular filling (diastole). With reduced filling, the ventricles pump less blood, resulting in decreased cardiac output and heart failure symptoms. Increased systemic venous pressure may occur from restricted diastolic filling, producing peripheral edema and hepatic failure. In addition, the patient’s recent occurrence of myocardial infarction may have injured the tissues of the heart, caused inflammation, and further contributed to pericarditis and pericardial effusion.
- To determine the contributing factors in acquiring Pericarditis. 3. What are the risk factors associated with Pericarditis? Aurora Health Care (n.d). Pericarditis. Retrieved on November 29, 2021 from https://www.aurorahealth care.org/services/heart-v ascular/conditions/pericar ditis
3. RISK FACTORS
The following are the specific risk factors of the patient in the scenario associated with pericarditis: ● Recurrent throat infections ● Infection from dental procedures ● A previous heart attack. Other risk factors for pericarditis include: ● Idiopathic or nonspecific causes
● Certain drugs, such as phenytoin for seizures and procainamide for irregular heartbeats, are rarely used.
- To classify the signs and symptoms of Pericarditis with rationale. 4. What are the signs and symptoms of Pericarditis? Cleveland Clinic. (2019). Pericarditis: Symptoms, Causes, Treatments. https://my.clevelandclinic. org/health/diseases/ 3-pericarditis Dry Cough: Symptoms, Causes, Treatment, Home Remedies. (2019). https://www.healthline.co m/health/dry-cough#com mon-causes Acute Pericarditis Clinical Presentation: History, Physical Examination. (2021). Retrieved 29 November 2021, from https://emedicine.medsca pe.com/article/156951-cli nical#b MedlinePlus. Fever. https://medlineplus.gov/fe ver.html
4. SIGNS AND SYMPTOMS
● Sudden-onset of chest pain. ○ Pericarditis can cause chest pain that is sharp and stabbing. This is caused by the heart rubbing against the pericardium. Pain increases with inspiration, swallowing, coughing, and rotation of the trunk. ● Non-productive cough. ○ They are usually the result of irritation in the airway, which may be due to the client’s throat infection. ● Fatigue. ○ This is due to the decreased cardiac output caused by reduced stroke volume due to impaired ventricular filling(diastole). It may also be a symptom of heart failure. The enlargement of the heart may constrict the pumping function of the heart thereby reducing cardiac output. ● Dyspnea can also occur along with respiratory splinting because of pain upon inspiration. ● (+) Pericardial Friction Rub ○ A pericardial friction rub is pathognomonic for acute pericarditis; the rub has a scratching, grating sound similar to leather rubbing against leather. It is the auscultatory
sound produced by the rubbing together of inflamed pericardial membranes in pericarditis. ○ Listen: (https://youtu.be/B2FEmI5RYHE) Waveform Wednesday: Perica… ● Vital Signs ○ Temperature: 39.2 °C ➢ This indicates a fever. It is usually a sign that your body is trying to fight an illness or infection. ○ Heart Rate 121 bpm ➢ The heart rate may increase to maintain cardiac output. ○ RR 14 cpm ➢ This is a normal finding. It is also known as eupnea. ○ BP 130/90 mmHg ➢ The elevated blood pressure may be due to compensation made by the heart through initiation of tachycardia to maintain cardiac output. Tachycardia can increase the patient’s cardiac output and blood pressure. In addition, it may also be due to severe chest pain that the client experiences which causes feelings of stress in the patient and increasing blood pressure.
er.edu/encyclopedia/cont ent.aspx?contenttypeid= 167&contentid=myoglobi n_blood#:~:text=This% test%20measures%20the %20amount,muscle%20c ells%20use%20for%20en ergy. CK-MB - Testing.com. (2021). https://www.testing.com/t ests/ck-mb/#:~:text=A% 0creatine%20kinase%2D MB%20(CK,damage% or%20skeletal%20muscl e%20damage. Medline Plus. (2021). Troponin Test. https://medlineplus.gov/la b-tests/troponin-test/ ● Chest X-Ray ○ Chest X-rays produce images of your heart, lungs, blood vessels, airways, and the bones of your chest and spine. It shows the position, size, and shape of the collarbone, breastbone, heart, airway, lungs, thoracic spine, ribs, lymph nodes, and blood vessels ○ Enlarged Cardiac Silhouette. Chest x-rays are generally normal, but a large pericardial effusion may appear as cardiomegaly. ○ The water bottle sign refers to the enlargement of the cardiac silhouette on posterior–anterior CXR. This is usually due to stretching of the pericardium secondary to large volume of fluid accumulating over a period of time. It causes the pericardium to appear like a water bottle. ○ Nursing Interventions:
➢ Assess scars in the thoracic area that might appear on the X-ray. ➢ Explain to the patient why the x-ray is being performed. ➢ Instruct the patient to remove all jewelry in the thoracic area. ● Echocardiogram ○ An echocardiogram uses sound waves to produce images of your heart. This common test allows your doctor to see your heart beating and pumping blood. ○ Moderate Cardiomegaly. An enlarged heart (cardiomegaly) means that your heart is bigger than normal. This is due to fluid accumulation in the pericardial cavity, which creates a pericardial effusion. ○ Nursing Intervention: ➢ Explain to the patient why and how the test is performed. ➢ Explain to the patient that they will not feel any pain during the test. ➢ Advise the patient that he doesn’t need to restrict food and fluids for the test. ● Complete Blood Count (CBC) test measures several components of blood to assess the patient for various disorders. ○ Hgb. measures how much hemoglobin your red blood cells
damage, but they don't show where the damage took place. ● CK-MB. A creatine kinase-MB (CK-MB) test may be used as a follow-up test to an elevated creatine kinase (CK) in order to determine whether the increase is due to heart damage or skeletal muscle damage. ○ CK-MB is normally undetectable or very low in the blood. ○ Chest pain and increased CK levels plus elevated CK-MB indicate that it is likely that a person has recently had a heart attack. Levels that drop, then rise again may indicate a second heart attack and/or ongoing heart damage. ○ 6.3 ng/mL. If CK-MB is elevated and the ratio of CK-MB to total CK (relative index) is more than 2.5-3, then it is likely that the heart was damaged. ● Troponin. A troponin test measures the level of troponin in your blood. Troponin is a type of protein found in the muscles of your heart. These proteins are released when the heart muscle has been damaged, such as occurs with a heart attack. ○ 2.2 ng/mL ○ If even a small level of troponin is found in your blood, it may mean there is some damage to your heart. ● NURSING INTERVENTIONS FOR BLOOD TEST:
○ Explain test procedure. Explain that slight discomfort may be felt when the skin is punctured. ○ Encourage them to avoid stress if possible because altered physiologic status influences and changes normal hematologic values. ○ Explain that fasting is not necessary. However, fatty meals may alter some test results as a result of lipidemia. ○ Apply manual pressure and dressings over the puncture site on removal of dinner. ○ Monitor the puncture site for oozing or hematoma formation. ○ Instruct to resume normal activities and diet.
- To identify and discuss the current medical management of Pericarditis. 6. What are the currently available medical management for Pericarditis and its significance in the course of care? Tabangcora, D. R. I. N. (2021, February 11). Antibiotics. Nurseslabs. https://nurseslabs.com/an tibiotics/#nursing_consid erations_for_antibiotics COLCHICINE. (2020). RobHolland. http://www.robholland.co m/Nursing/Drug_Guide/d ata/monographframes/C 08.html MacGill, M. (2021, July 21). Everything you need to know about NSAIDs. MedicalNewsToday. https://www.medicalnews today.com/articles/ 1
6. MEDICAL MANAGEMENT
Antibiotics Antibiotics are potent antibiotics that are used to treat a variety of ailments. It disrupts essential processes or structures in the bacterial cell. This either kills the bacteria or slows down bacterial growth. Depending on these effects an antibiotic is said to be bactericidal or bacteriostatic. A bactericidal antibiotic kills the
aches, toothaches, common cold, and headaches. It also treats inflammation such as strains and sprains, and pain from arthritis. The main mechanism of action of these drugs is the non-selective, reversible inhibition of the cyclooxygenase enzymes COX- and COX-2 (coded for by PTGS1 and PTGS2, respectively). This may be prescribed for pain relief and inflammation during the acute phase of pericarditis. These agents also hasten reabsorption of fluid in patients with rheumatic pericarditis. However, indomethacin (Indocin) is an NSAID that is contraindicated because it may decrease coronary blood flow. Nursing considerations: ● Assess for allergy to ibuprofen or other NSAIDs ● Assess other medication for possible interactions ● Be aware that the patient may be at increased risk of CV event, GI bleeding, monitor accordingly. ● Administer drug with food or after meals if GI upset occurs. ● Discontinue drug if eye changes, symptoms of hepatic impairment, or renal impairment occur. Corticosteroids
Corticosteroids are man-made drugs that closely resemble cortisol, a hormone that your adrenal glands produce naturally. Corticosteroids are often referred to by the shortened term "steroids." Corticosteroids modify the functions of epidermal and dermal cells and of leukocytes participating in proliferative and inflammatory skin diseases. After passage through the cell membrane corticosteroids react with receptor proteins in the cytoplasm to form a steroid-receptor complex. These are strong medications that fight inflammation for pericarditis and may be prescribed if the pericarditis is severe or if the patient does not respond to NSAIDs. Nursing considerations: ● Assess for possible contraindications and cautions. ● Monitor and report signs of peptic ulcer, including heartburn, nausea, vomiting blood, tarry stools, and loss of appetite. ● Assess signs of increased intracranial pressure in children, including changes in mood and behavior, decreased
to 2 mg orally on Day 1 followed by 0.5 to 1 mg orally daily for 6 months. Nursing Considerations: ● Monitor for dose-related adverse effects; they are most likely to occur during the initial course of treatment. ● Monitor for early signs of colchicine toxicity including weakness, abdominal discomfort, anorexia, nausea, vomiting, and diarrhea, regardless of administration route. Report to physician. To avoid more serious toxicity, drugs should be discontinued promptly until symptoms subside. ● Avoid fermented beverages such as beer, ale, and wine as they may precipitate gout attack. The physician may allow distilled alcoholic beverages in moderation. ● Do not breast feed without consulting a physician.
- To recognize the specific medications indicated for the client’s condition. 7. What are the mechanism of action and therapeutic effect of the ordered medications and its correspondin g nursing interventions ?
ACETAMINOPHEN,
PARACETAMOL. (2019).
RobHolland. http://www.robholland.co m/Nursing/Drug_Guide/d ata/monographframes/A 06.html AZITHROMYCIN. (2020). RobHolland. http://www.robholland.co
7. SPECIFIC MEDICATIONS FOR PERICARDITIS
Azithromycin
m/Nursing/Drug_Guide/d ata/monographframes/A 92.html Azithromycin is used to treat a wide variety of bacterial infections. It is a macrolide-type antibiotic. It works by stopping the growth of bacteria. This medication will not work for viral infections (such as common cold, flu). Unnecessary use or misuse of any antibiotic can lead to its decreased effectiveness. It binds to the 23S rRNA of the bacterial 50S ribosomal subunit. It stops bacterial protein synthesis by inhibiting the transpeptidation/translocation step of protein synthesis and by inhibiting the assembly of the 50S ribosomal subunit. In the scenario, it is administered 500 mg OD for 5 days to treat the infection of the patient Nursing considerations: ● Monitor for and report loose stools or diarrhea, since pseudomembranous colitis (see Appendix F) must be ruled out. ● Monitor PT and INR closely with concurrent warfarin use. ● Direct sunlight (UV) exposure should be minimized during therapy with drugs. ● Take aluminum or magnesium antacids 2 h before or after the drug. ● Report onset of loose stools or diarrhea. ● Do not breast feed while taking this drug without consulting a physician. Paracetamol
psychological dependence (withdrawal has been associated with restless and excited responses). ● Do not take other medications (e.g., cold preparations) containing acetaminophen without medical advice; overdosing and chronic use can cause liver damage and other toxic effects. ● Do not self-medicate adults for pain more than 10 d (5 d in children) without consulting a physician. ● Do not use this medication without medical direction for: fever persisting longer than 3 d, fever over 39.5° C (103° F), or recurrent fever. ● Do not give children more than 5 doses in 24 h unless prescribed by a physician. ● Do not breast feed while taking this drug without consulting a physician.
- To determine the surgical procedures associated with pericarditis 8. What is the surgical management for pericarditis? Themes, U. (2016, July 21). Pericardiocentesis, Assisting. Nurse Key. https://nursekey.com/peri cardiocentesis-assisting/ Pericardial Window. (2019). Johns Hopkins Medicine. https://www.hopkinsmedi cine.org/health/treatment-
8. SURGICAL MANAGEMENT
Pericardiocentesis
tests-and-therapies/peric ardial-window Pericardiocentesis. (2019). Johns Hopkins Medicine. https://www.hopkinsmedi cine.org/health/treatment- tests-and-therapies/peric ardiocentesis Pericardiocentesis is a procedure done to remove fluid that has built up in the sac around the heart (pericardium). It's done using a needle and small catheter to drain excess fluid. A fibrous sac known as the pericardium surrounds the heart. During pericardiocentesis, a doctor inserts a needle through the chest wall and into the tissue around the heart. Once the needle is inside the pericardium, the doctor inserts a long, thin tube called a catheter. The doctor uses the catheter to drain excess fluid. The catheter may come right out after the procedure. In pericarditis, it may be performed to assist in identification of the cause or relieve symptoms, especially if there are signs and symptoms of heart failure or tamponade. Nursing Considerations: ● Verify that the laboratory and imaging studies have been completed as ordered and that the results are in the patient’s medical record. Notify the doctor of any abnormal results.
