Which findings would cause the nurse to suspect that a post-coronary artery bypass patient might be developing cardiac tamponade? Note: Credit will be given only if all correct choices and no incorrect choices are selected

Question

Select all that apply. 1. Widening pulse pressure
2. Increased jugular vein distension
3. Decreasing central venous pressure (CVP)
4. Muffled heart sounds
5. Lack of pleural (chest) tube drainage

Answer 1

2,4,5
Rationale 1: The pulse pressure will narrow, not widen, as fewer pressure differences are noted between the systolic and diastolic pressures.
Rationale 2: As the heart is compressed within its own pericardial sac from fluid accumulation, the ability to expand is limited because fluid accumulates outside the heart to the point in which contraction cannot occur. The pressures back up and create increased pressure as seen with engorging jugular veins.
Rationale 3: The CVP increases not decreases as the backup occurs when the ventricles cannot pump and circulate the blood due to its limited motion.
Rationale 4: As the heart is compressed within its own pericardial sac from fluid accumulation, the ability to expand is limited because fluid accumulates outside the heart to the point in which contraction cannot occur. The fluid surrounding the heart muffles the heart sounds.
Rationale 5: Fluid ceases to drain from the pericardial tubes into the pleural (chest) tubes. As the heart is compressed within its own pericardial sac from fluid accumulation, the ability to expand is limited because fluid accumulates outside the heart to the point in which contraction cannot occur.