Following cardiac surgery, the nurse suspects the patient may be developing a cardiac tamponade. Which of the following clinical manifestations would support this diagnosis? Select all that apply
A)
Muffled heart tones
B)
Narrowed pulse pressure
C)
Low BPâ€"84/60
D)
Heart rate 78
E)
Bounding femoral pulse
Ans:
A, B, C
Feedback:
Cardiac tamponade results in increased intracardiac pressure, progressive limitation of ventricular diastolic filling, and decreased stroke volume and cardiac output. This accumulation of fluid results in tachycardia, elevated CVP, jugular vein distention, fall in systolic BP, narrowed pulse pressure, and signs of shock. Heart sounds may be muffled. A pulse rate of 78 is normal (not tachycardic). With pulsus paradoxus, the arterial pulse as palpated at the carotid or femoral artery becomes weakened (not bulging) or absent with inspiration.
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