Cardiac tamponade is suspected in a patient diagnosed with pericarditis. What assessment data would assist the nurse in determining the presence of this complication?
1. Changes in systolic blood pressure during inspiration
2. Arterial blood gases
3. The rhythm of the pulse in relation to inspiration and expiration
4. A cardiac murmur that occurs during systole
1
Rationale 1: A pulsus paradoxus is an important diagnostic clue when evaluating for the presence and progression of cardiac tamponade. It is defined as a drop greater than 10 mmHg in systolic blood pressure (BP) during inspiration. The BP normally decreases during inspiration, but by less than 10 mmHg. A drop of greater than 10 mmHg occurs when there is increased thoracic pressure due to pericardial swelling.
Rationale 2: Arterial blood gas measurement is not specific to cardiac tamponade.
Rationale 3: As tamponade increases, there are changes in cardiac rate and rhythm, but they are not associated with inspiration and expiration.
Rationale 4: The presence of a systolic murmur is not specific to cardiac tamponade.
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