Medical Surgical Nursing

c. Weak or absent

peripheral pulses

d. Altered level of

consciousness

e. Bulging neck veins

3. Prepare patient for cardiac

ultrasound to aid in diagnosis of

pericardial effusion and cardiac

tamponade.

4. If cardiac tamponade develops,

prepare patient for emergency

pericardiocentesis.

common fatal sequela of

pericarditis. Signs of an

effusion include a

paradoxical pulse (> 10

mm Hg drop in blood

pressure during

inspiration) and signs of

shock due to

compression of the heart

by a large effusion.

Cardiac tamponade

exists when the patient

is severely compromised

hemodynamically.

3. Cardiac ultrasound is

useful in visualizing

pericardial effusions and

cardiac tamponade.

4. Cardiac tamponade is a

life-threatening

condition, with a high

mortality rate.

Immediate aspiration of

fluid from the

pericardial space is

essential.

 Patient has normal

heart sounds

Hypertension

1. Monitor and record blood
   pressure as indicated.


2. Administer antihypertensive
   medications as prescribed.


3. Encourage compliance with
   dietary and fluid restriction
   therapy.


4. Teach patient to report signs of
   fluid overload, vision changes,
   headaches, edema, or seizures.

1. Provides objective data

for monitoring. Elevated

levels may indicate non-

adherence to the

treatment regimen.

2. Antihypertensive

medications play a key

role in treatment of

hypertension associated

with chronic renal

failure.

3. Adherence to diet and

fluid restrictions and

dialysis schedule

prevents excess fluid

and sodium

accumulation.

4. These are indications of

in-adequate control of

hypertension and the

need to alter therapy.

 Blood pressure

within normal

limits

 Reports no

headaches, visual

problems, or

seizures

 Edema is absent

 Demonstrates

compliance with

dietary and fluid

restrictions

Anemia