Cardiac tamponade is suspected in a client who has undergone a repair of a ventricular aneurysm. What assessment data would assist the nurse in determining the presence of cardiac tamponade?
1. The distance in mm's of Hg between the Korotkoff sounds during inspiration, while taking the blood pressure
2. The rhythm of the pulse in relation to the client's inspiration and expiration
3. Arterial blood gases
4. A cardiac murmur that occurs during systole
The distance in mm's of Hg between the Korotkoff sounds during inspiration, while taking the blood pressure
Rationale: A pulse's paradox is an important diagnostic clue when evaluating for the presence and progression of cardiac tamponade. It is defined as a greater than 10-mm drop in systolic blood pressure (BP) during inspiration. The BP normally decreases during inspiration, but it is less than 10 mmHg. A paradox of greater than 10 mmHg is present when there is increased thoracic pressure, which is due to pericardial swelling. There is normally no difference in the rhythm of the pulse during inspiration and expiration. Arterial blood gases changes and the presence of cardiac murmurs are not specific to cardiac tamponade.
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