ASSESSMENT NURSING NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS ANALYSIS
Objective: Cardiac Cardiac After nursing  Monitor Vital  To obtain  Patient
tamponade tamponade is a interventions that signs and baseline data maintained
 Chest pain related to caused by the patient will be able characteristic cardiac output
 SOB increased accumulation of to: s of blood  To monitor any
 Enlargement central venous fluid in the pressure at worsening of the  Patient
of the veins pressure pericardial space,  Maintain least every quality of cardiac Demonstrated
in the neck resulting in adequate 15 minutes output relief of pain,
 Restlessness reduced cardiac stable vital
 Swelling of ventricular filling output  Monitor ECG  To increase the signs and
arms and and subsequent continuously oxygen level and absence of
legs hemodynamic  Demonstrate for any signs achieve an SpO2 restlessness
compromise relief of pain, of value within
Vital Signs: stable vital dysrhythmias target range  Patient showed
BP – 150/90 mmHg signs and improved
RR – 29 cpm absence of  Administer  To prevent tissue
HR – 120 bpm The fluid pushes restlessness supplemental further perfusion
Temp – 36.9 on the heart so it oxygen as complications
O2sat – 90% is not able to  Show prescribed  Patient
pump normally improve  Pericardiocentesis sustained
tissue  Administer & pericardiotomy normal weight
perfusion medications can be done to and is free
as prescribed facilitate the from edema
If left untreated,  Sustain removal of
cardiac normal  Prepare the pericardial fluid
tamponade can weight and patient for
cause shock and, be free from surgery if
ultimately, death. edema indicated