Pericarditis is an inflammation of the pericardium, which is the membranous sac that encloses the heart and great vessels. The inflammatory response causes an accumulation of leukocytes, platelets, fibrin, and fluid between the parietal and the visceral layers of the pericardial sac, thus producing a variety of symptoms, depending on the amount of fluid accumulation, how quickly it accumulates, and whether the inflammation resolves after the acute phase or becomes chronic.
An acute pericardial effusion is caused by an accumulation of fluid in the pericardial sac. The fluid accumulation interferes with cardiac function by compressing the cardiac chambers. Chronic constrictive pericarditis usually begins as an acute inflammatory pericarditis and progresses over time to a chronic, constrictive form because of pericardial thickening and stiffening. The thickened, scarred pericardium becomes nondistensible and decreases diastolic filling of the cardiac chambers and cardiac output. Chronic pericardial effusion is a gradual accumulation of fluid in the pericardial sac. The pericardium is slowly stretched and can accommodate more than 1 L of fluid at a time.
Between 26% and 86% of people with pericarditis have illnesses that are considered idiopathic (occurring without a known cause). Pericarditis may also be classified etiologically into three broad categories: infectious pericarditis, noninfectious pericarditis, and pericarditis presumably related to hypersensitivity or autoimmunity. Infectious pericarditis may be caused by a viral infection such as the coxsackie B virus. Pyrogenic, tuberulous, mycotic, syphilitic, and parasitic infections may also cause pericarditis. Noninfectious pericarditis may be caused by a number of factors, including acute myocardial infarction, trauma, aortic aneurysm (with leakage into the pericardial sac), uremia, sarcoidosis, and myxedema. Both primary tumors, either benign or malignant, and metastatic tumors in the pericardium may cause pericarditis. Other causes include cholesterol and chylopericardium.
Pericarditis is also thought to be related to hypersensitivity or autoimmunity. Rheumatic fever and collagen vascular disease, such as systemic lupus erythematosus, rheumatoid arthritis, and scleroderma, may cause pericarditis. Some drugs, such as procainamide and hydralazine, are thought to cause pericarditis, as can postcardiac injury, such as Dressler’s syndrome, and postpericardiotomy.
Nursing care plan assessment and physical examination
Acute inflammatory pericarditis is most frequently idiopathic; however, the patient may have a history of a viral, bacterial, fungal, or parasitic infection. Take a detailed history of the patient’s symptoms, especially pain. Ask the patient to describe the pain: Is it dull or sharp, and is it persistent? Is the location of the pain retrosternal or left precordial and radiating to the neck, left arm, and trapezius ridge? Ask if the pain is worsened by trunk movement, position, and deep inspiration. Ask about fever, cough, dyspnea, dysphagia, hiccups, nausea, and abdominal pressure (because of the compression of surrounding tissues by the enlarged pericardial sac).
The patient with a chronic pericardial disease may reveal a history of myocardial infarction (Dressler’s syndrome), tuberculosis, chronic renal failure, radiation therapy, malignancies, connective tissue disease, and acquired immunodeficiency syndrome (AIDS). Note a history of increasing dyspnea, fatigue, loss of appetite, nausea, and cough. Chest pain is not usually associated with chronic pericarditis.
Check the patient’s vital signs for tachycardia, tachypnea, and fever. If there is an effusion, the blood pressure may be low and a pulsus paradoxus may be present (an abnormal drop in systolic pressure with inspiration). Inspect the patient’s neck for vein distension because of elevated jugular venous pressures that are caused by chronic pericarditis. Auscultate for heart sounds to establish a pericardial friction rub. Although the presence of a pericardial friction rub is a significant finding, the absence of a rub is not because pericardial friction rub is transient.
Because of severe chest pain, patients with acute pericarditis may be in distress. The patient may be fearful of having a myocardial infarction. Assess the patient’s ability to cope with a sudden illness and severe pain.
Nursing care plan primary nursing diagnosis: Pain (acute) related to swelling and inflammation of the heart or surrounding tissue.
Nursing care plan intervention and treatment plan
Pericarditis is treated by correcting the underlying cause and therefore relieving the signs and symptoms. Acute pericarditis is treated with analgesic and anti-inflammatory agents. Acute pericardial effusions are treated according to the hemodynamic effect on the myocardium. An acute effusion that causes a decreased cardiac output is an indication for pericardiocentesis, which allows for fluid to be removed from the pericardial sac. Cardiac compression is relieved, and cardiac output returns. Other alternatives are a pericardiotomy, which is a surgical incision in the pericardial sac, or pericardial window (fenestration), which is the removal of one or more small portions of the pericardial sac. These surgical procedures are used when pericardiocentesis is unsuccessful or must be repeated because of continued accumulation of fluid.
Chronic pericarditis, with or without an effusion, may require a pericardectomy, which involves a thoracotomy incision and carries a much higher mortality (5% to 14%) than the other procedures. Note that, to halt the hemorrhage, a rapidly accumulating tamponade from hemorrhage into the pericardiac space should be managed surgically rather than by pericardiocentesis.
Place the patient in a high Fowler position. Use pillows to increase the patient’s comfort, and encourage the patient to sit upright and lean slightly forward rather than lie supine. If the upright position does not alleviate the pain, have the patient try a side-lying position for 10 minutes. If the patient needs to perform coughing and deep-breathing exercises, provide instruction on splinting the chest with pillows to decrease the pain.
Remain with the patient during periods of increased pain and discomfort. Encourage the patient and family to verbalize their fears and concerns and to ask questions about the treatment and course of the disorder. Inform the patient and family about pericarditis and its causes.
Explain all procedures. Assist the patient and family in distinguishing acute pericarditis from myocardial infarction. Teach them about continuing medications as prescribed even after the pain is gone but to taper use of steroids.
Nursing care plan discharge and home health care guidelines
Be sure the patient understands any pain medication prescribed, including dosage, route, action, and side effects. The patient and family or significant other needs to understand the importance of decreased activity until the chest pain is completely gone. If the patient has undergone a surgical procedure, follow the activity restrictions for a thoracotomy.