PERICARDITIS
Introduction
Pericarditis is the inflammation of the pericardium,
a double-layered sac that encloses the heart and the roots of the great vessels (aorta, pulmonary artery, vena cavae). This sac provides protection, lubrication, and helps to anchor the heart within the chest cavity. When inflamed, the layers of the pericardium can rub against each other, causing characteristic pain and other symptoms.
The Pericardium
The pericardium is a thin, two-layered, fluid-filled sac that covers the outer surface of the heart.(normal volume of the fluid is around 50ml)
- It also prevents the heart from over-expanding when blood volume increases, which keeps the heart functioning efficiently.
- It shields the heart from infection or malignancy and contains the heart in the chest wall.
Etiology (Causes) of Pericarditis
Pericarditis can be caused by various factors, with idiopathic (unknown cause) being the most common, often suspected to be viral in origin.
Infections:
- Viral: Most common cause of acute pericarditis (e.g., coxsackievirus, echovirus, influenza, HIV).
- Bacterial: Less common but more severe (e.g., tuberculosis, staphylococcal, streptococcal).
- Fungal and Parasitic: Rare, typically in immunocompromised individuals.
Autoimmune Diseases: Systemic inflammatory conditions like Systemic Lupus Erythematosus (SLE), rheumatoid arthritis, scleroderma, and inflammatory bowel disease.
Myocardial Infarction (Heart Attack):
- Early Post-MI Pericarditis: Occurs within a few days of a heart attack due to inflammation from myocardial necrosis.
- Dressler's Syndrome (Post-cardiac Injury Syndrome): An autoimmune reaction occurring weeks to months after a heart attack, cardiac surgery, or trauma.
Uremia: Occurs in patients with kidney failure due to the buildup of toxins (uremic pericarditis).
Malignancy: Cancer spreading to the pericardium (e.g., lung cancer, breast cancer, lymphoma).
Trauma: Injury to the chest or heart, including iatrogenic (due to medical procedures).
Radiation Therapy: Can lead to acute or chronic pericarditis.
Drugs: Certain medications (e.g., procainamide, hydralazine, isoniazid) can induce drug-induced lupus-like syndromes with pericardial involvement.
Metabolic Disorders: Hypothyroidism (myxedema).
According to Culprit
Infectious Pericarditis
Infections are a common cause, particularly viral, leading to acute pericarditis. Other pathogens are less frequent but can cause more severe disease.
Viral: This is the most common cause of acute pericarditis. Viruses directly infect and inflame the pericardium.
- Common culprits: Coxsackievirus B (most frequent), Adenovirus, Echovirus, Influenza virus (A and B), Parvovirus B19, Herpesviruses (CMV, EBV, VZV), HIV.
- Mechanism: Direct viral invasion and replication within pericardial cells, triggering an inflammatory response.
Bacterial: Less common in developed countries due to widespread antibiotic use, but can be severe, often leading to purulent (pus-filled) pericarditis.
- Pyogenic (Pus-forming) Bacteria: Staphylococcus aureus, Streptococcus pneumoniae (Pneumococci), other Streptococci.
- Routes of Infection: Hematogenous spread (from bloodstream, e.g., septicemia), direct extension from adjacent infections (e.g., pneumonia, empyema), or direct inoculation (e.g., cardiac surgery, trauma).
- Tuberculosis (TB): A significant cause in endemic areas. Tuberculous pericarditis can lead to chronic, constrictive pericarditis.
Fungal: Rare, typically seen in immunocompromised individuals.
- Examples: Histoplasma capsulatum, Candida species, Aspergillus.
Parasitic: Extremely rare in most regions, but important in specific geographic areas.
- Example: Toxoplasma gondii, Entamoeba histolytica (amoebic pericarditis), Echinococcus (hydatid cyst).
Non-Infectious Pericarditis
A significant proportion of pericarditis cases are not caused by direct infection but rather by systemic conditions, injury, or other inflammatory processes.
Autoimmune/Inflammatory Diseases: Conditions where the immune system mistakenly attacks the body's own tissues.
- Systemic Lupus Erythematosus (SLE): Pericarditis is a common manifestation of lupus.
- Rheumatoid Arthritis (RA): Less common, but can cause pericardial involvement.
- Scleroderma (Systemic Sclerosis): Can lead to pericardial effusion and thickening.
- Ankylosing Spondylitis: A chronic inflammatory disease primarily affecting the spine, but can have cardiac manifestations.
- Inflammatory Bowel Disease (IBD): (Crohn's disease, Ulcerative colitis) can have extra-intestinal manifestations, including pericarditis.
- Rheumatic Fever: An inflammatory disease that can develop as a complication of untreated streptococcal infection, affecting the heart (rheumatic carditis), joints, brain, and skin. Pericarditis is one component of carditis.
Post-Cardiac Injury Syndromes: Inflammatory reactions following damage to the heart or pericardium.
- Dressler's Syndrome (Post-Myocardial Infarction Syndrome): An immune-mediated inflammation of the pericardium that occurs weeks to months after a myocardial infarction (heart attack).
- Post-Pericardiotomy Syndrome (PPS): Occurs after cardiac surgery (e.g., bypass surgery, valve replacement, pacemaker insertion) due to inflammation from surgical trauma.
- Trauma: Direct chest trauma (e.g., blunt force, penetrating injuries) can cause pericardial injury and inflammation.
Metabolic Disorders:
- Uremia: Occurs in patients with severe kidney failure (end-stage renal disease) due to the accumulation of metabolic toxins that irritate the pericardium. It typically does not respond to anti-inflammatory drugs and requires dialysis.
- Myxedema (Severe Hypothyroidism): Can lead to pericardial effusion due to increased capillary permeability and fluid retention.
Malignancy (Cancer):
- Metastatic Cancer: Cancer cells can spread to the pericardium from primary tumors (e.g., lung cancer, breast cancer, lymphoma, leukemia, melanoma). This often leads to malignant pericardial effusion.
- Primary Pericardial Tumors: Very rare (e.g., mesothelioma).
Radiation-Induced Pericarditis: Can occur as a complication of radiation therapy to the chest for cancer treatment (e.g., breast cancer, Hodgkin's lymphoma). Can manifest acutely or years after treatment.
Acute Myocardial Infarction (MI): Early pericarditis can occur in the first few days after a transmural (ST-elevation) MI due to inflammation over the necrotic myocardial tissue.
Aortic Dissection: If an aortic dissection extends into the pericardial sac, it can cause hemopericardium (blood in the pericardial sac) and acute pericarditis-like pain. This is a medical emergency.
Drug-Induced Pericarditis: Certain medications can trigger a lupus-like syndrome or direct pericardial inflammation.
- Examples: Isoniazid, Procainamide, Hydralazine, Phenytoin, Minoxidil, Cyclosporine, Anthracyclines (some chemotherapy drugs).
Idiopathic Pericarditis: When no specific cause can be identified despite thorough investigation, it is termed idiopathic. This is the most common diagnosis for acute pericarditis, often presumed to be viral.
Pathophysiology of Pericarditis
- The acute inflammatory response in pericardium can produce either serous or purulent fluid, or a dense fibrinous material. In viral pericarditis, the pericardial fluid is most commonly serous, is of low volume, and resolves spontaneously.
- Neoplastic, tuberculous, and purulent pericarditis may be associated with large effusions that are exudative, hemorrhagic, and leukocyte filled.
- Gradual accumulation of large fluid volumes in the pericardium, even up to 250 mL, may not result in significant clinical signs.
Clinical Manifestations of Pericarditis
Beck's triad is a collection of three medical signs associated with acute cardiac tamponade.
The signs are:-
- Low arterial blood pressure
- Distended neck veins
- Distant, muffled heart sounds.
Chest pain symptoms associated with pericarditis can be described as:
- Sharp and stabbing chest pain (caused by the heart rubbing against the pericardium). May increase with coughing, deep breathing or lying flat.
- Can be relieved by sitting up and leaning forward .
- You may also feel the need to bend over or hold your chest to breathe more comfortably.
Other clinical features include;
The symptoms of pericarditis can range from mild to severe and may mimic other cardiac conditions. The classic symptoms include:
- Chest Pain:
- Character: Typically sharp, stabbing, or pleuritic (worsens with deep breath, cough, or swallowing). Can also be dull, aching, or pressure-like.
- Location: Usually substernal (behind the breastbone) or precordial (over the heart), often radiating to the left shoulder, neck, trapezius ridge (shoulder blade area), or back.
- Aggravating Factors: Worsens with lying flat (supine position), deep inspiration, coughing, swallowing, and sometimes with movement.
- Relieving Factors: Often eased by sitting up and leaning forward. This position reduces pressure on the inflamed pericardium.
- Pericardial Friction Rub: A characteristic scratching, grating, or squeaking sound heard during auscultation of the heart, caused by the inflamed pericardial layers rubbing against each other. It is best heard with the diaphragm of the stethoscope over the left sternal border, with the patient leaning forward and exhaling. This is a highly specific sign.
- Dyspnoea (Shortness of Breath): May be due to pleuritic chest pain limiting deep breaths, or in severe cases, due to pericardial effusion leading to cardiac tamponade.
- Low-Grade Fever: Common, especially in infectious causes.
- Fatigue and Malaise: Generalized symptoms due to the inflammatory process.
- Palpitations: Can occur if the inflammation irritates the heart muscle or conductive system.
- Cough: May be present due to irritation of the airways or associated pleural inflammation.
- Anxiety: Often results from the frightening nature of chest pain and other symptoms.
Cardinal Signs and Symptoms of Pericarditis (Mnemonics)
Remember “Friction” (as previously noted) and also consider the more comprehensive "PERICARDITIS" mnemonic for key features:
- Friction rub pericardial (sounds like a grating, scratching sound), Fever
- Radiating substernal pain to left shoulder, neck or back
- Increased pain when in supine position (leaning forward relieves pain)
- Chest pain that is stabbing (will feel like a heart attack)
- Trouble breathing when lying down (supine position)
- Inspiration or coughing makes pain worse
- Overall feels very sick and weak
- Noticeable ST segment elevation on ECG (often widespread concave up)
P.E.R.I.C.A.R.D.I.T.I.S. Mnemonic:
- Pleuritic chest pain (worsens with breathing)
- ECG changes (widespread ST elevation, PR depression)
- Rub (pericardial friction rub)
- Increased pain with supine position
- Cough, fever, malaise (flu-like symptoms)
- Autoimmune disease history
- Radiation to trapezius ridge (classic finding)
- Difficulty breathing (dyspnoea)
- Increased pain with inspiration
- Treatment with NSAIDs (often effective)
- Idiopathic or Infectious cause (viral most common)
- Sitting up and leaning forward relieves pain
Types of Pericarditis
Pericarditis is classified based on its temporal course and characteristics:
- Acute Pericarditis:
- Onset: Sudden and rapid.
- Duration: Typically resolves within 3 weeks.
- Characteristics: Often associated with severe chest pain and a pericardial friction rub. Usually self-limiting, but can recur.
- Common Causes: Viral infections, idiopathic.
- Incessant Pericarditis:
- Duration: Lasts for more than 4-6 weeks but less than 3 months, with continuous presence of symptoms and signs without remission.
- Characteristics: Symptoms persist despite initial treatment, indicating ongoing inflammation.
- Recurrent Pericarditis:
- Onset: Occurs after a symptom-free interval of at least 4-6 weeks following an acute episode.
- Characteristics: Can be very distressing for patients, with repeated episodes of chest pain and inflammation. Often requires long-term management.
- Causes: Often idiopathic, but can be associated with autoimmune conditions.
- Chronic Pericarditis:
- Duration: Develops slowly and lasts for more than 3 months.
- Characteristics: Can lead to pericardial thickening and fibrosis, potentially progressing to more serious conditions like constrictive pericarditis. Symptoms may be less acute but persistent.
- Constrictive Pericarditis:
- Nature: A serious complication of chronic pericarditis where the pericardium becomes thick, rigid, and fibrotic.
- Mechanism: This hardened sac restricts the heart's ability to expand and fill with blood properly during diastole.
- Consequences: Leads to impaired cardiac filling, elevated venous pressures, and symptoms of right-sided heart failure (e.g., severe edema, ascites, jugular venous distension).
Investigations for Pericarditis
Diagnosing pericarditis involves a combination of clinical assessment, specific tests to confirm inflammation, identify the cause, and assess for complications.
Medical History and Physical Exam:
- History: Detailed inquiry about chest pain characteristics (onset, location, radiation, aggravating/relieving factors), fever, recent infections, autoimmune conditions, trauma, medications, and travel history.
- Physical Exam:
- Pericardial Friction Rub: The hallmark sign, a scratching or squeaking sound best heard with the diaphragm of the stethoscope over the left sternal border, with the patient leaning forward and holding their breath in expiration.
- Signs of Pericardial Effusion/Tamponade: Muffled heart sounds, pulsus paradoxus, jugular venous distension, hypotension (late signs).
- Signs of Systemic Disease: Rash, joint swelling (suggesting autoimmune disease).
Electrocardiography (ECG):
- Classic Findings: Widespread ST-segment elevation (concave upwards) in most leads (unlike MI, which is localized and convex), and PR-segment depression (especially in leads II, aVF, V5, V6). These changes reflect inflammation of the epicardium.
- Evolution: ECG changes typically evolve over days to weeks, from ST elevation to T-wave inversion, then normalization.
Echocardiography (Echo):
- Purpose: The most important imaging test. It is essential for assessing for pericardial effusion (fluid around the heart) and its hemodynamic significance (e.g., signs of cardiac tamponade).
- Information Provided: Can visualize the pericardium, quantify effusion size, assess cardiac chamber size and function, and identify signs of cardiac tamponade (e.g., right ventricular diastolic collapse, paradoxical septal motion).
Cardiac CT scan/MRI:
- Cardiac Computed Tomography (CT): Useful for visualizing pericardial thickening, calcification (in constrictive pericarditis), and large effusions. Can help differentiate pericardial disease from myocardial disease.
- Cardiovascular Magnetic Resonance Imaging (MRI): Provides excellent soft tissue characterization. It is the gold standard for detecting pericardial inflammation, edema, and fibrosis. Can also differentiate constrictive pericarditis from restrictive cardiomyopathy.
Blood Tests:
- Inflammatory Markers:
- C-reactive protein (CRP): Usually elevated and helps confirm inflammation. Serial CRP levels can monitor disease activity and response to treatment.
- Erythrocyte Sedimentation Rate (ESR): Also typically elevated, another general marker of inflammation.
- Cardiac Biomarkers:
- Troponin (I or T): May be mildly elevated in pericarditis if there is associated myocardial inflammation (myopericarditis), indicating some degree of myocardial cell injury. Higher levels raise suspicion for myocarditis or myocardial infarction.
- CK-MB and Myoglobin: Less specific than troponin for cardiac injury, but may be checked.
- Infectious Workup: Depending on clinical suspicion, tests for specific pathogens:
- Viral Serology: (e.g., Coxsackievirus antibodies) may be done but often not helpful for acute management.
- Bacterial Cultures: Blood cultures if sepsis is suspected. Pericardial fluid culture if pericardiocentesis is performed.
- TB Tests: Tuberculin skin test (PPD), interferon-gamma release assays (IGRAs), and acid-fast bacilli (AFB) stains/cultures on pericardial fluid.
- Autoimmune Markers:
- Antinuclear Antibodies (ANA), Rheumatoid Factor (RF), Anti-dsDNA: If autoimmune disease is suspected.
- Renal Function Tests:
- Blood Urea Nitrogen (BUN) and Creatinine: To assess for uremia in patients with kidney disease.
Radionuclide Scanning (e.g., PET scan): May be used in complex cases to detect areas of active inflammation or malignancy, particularly if other tests are inconclusive.
Pericardiocentesis and Pericardial Biopsy:
- Pericardiocentesis: A procedure to drain fluid from the pericardial sac. Indicated for large effusions, signs of cardiac tamponade, or for diagnostic purposes (e.g., to analyze fluid for infection, malignancy, or specific inflammatory markers).
- Pericardial Biopsy: Rarely performed, but may be considered in cases of chronic or recurrent pericarditis with an unknown etiology, or suspicion of specific infiltrative diseases.
Nursing Interventions and Management of Pericarditis
Nursing care for patients with pericarditis focuses on pain management, monitoring for complications, providing emotional support, and patient education.
General Principles of Management
- Goal: Relieve pain, reduce inflammation, prevent complications (e.g., cardiac tamponade, constrictive pericarditis), and treat the underlying cause.
- Setting: Mild cases may be managed outpatient, while moderate to severe cases, or those with complications, require hospitalization.
Management for Mild Pericarditis
Patients with mild, uncomplicated pericarditis often respond well to conservative measures and oral medications.
Pain Assessment and Management:
- Assess Patient’s Pain: Characterize the pain (sharp, stabbing, dull), location, radiation, and aggravating/relieving factors. Use a pain scale (e.g., 0-10) to quantify severity. Pericarditis pain can be excruciatingly painful.
- Positioning for Pain Relief: Keep patient in a high Fowler’s position (sitting upright) or encourage leaning forward. Avoid a supine (lying flat) position, as it exacerbates pericardial pain by increasing pressure on the inflamed pericardium.
Monitoring for Complications (e.g., Cardiac Tamponade):
- Constant Vigilance: Cardiac tamponade is a life-threatening complication that requires immediate recognition and intervention.
- Key Signs to Monitor (Beck's Triad):
- Muffled or Distant Heart Sounds: Due to fluid buildup around the heart.
- Jugular Venous Distension (JVD) with Clear Lungs: Increased pressure in the right atrium due to restricted filling, but without pulmonary congestion typical of heart failure.
- Hypotension: Decreased cardiac output due to compression of the heart.
- Pulsus Paradoxus: A significant (typically >10 mmHg) drop in systolic blood pressure during inspiration. This is a classic sign of cardiac tamponade and severe restrictive filling.
- Tachycardia: The heart attempts to compensate for reduced cardiac output by increasing its rate.
- Other Signs: Narrowed pulse pressure, decreased urine output, cool extremities, altered mental status (signs of decreased perfusion).
Administer Medications as Prescribed by Physician:
- First-line Therapy:
- High-dose Aspirin: Often used, especially for post-MI pericarditis. It has both anti-inflammatory and anti-platelet effects.
- NSAIDs (Nonsteroidal Anti-Inflammatory Drugs): Such as Ibuprofen, Indomethacin. These are the cornerstone of treatment for acute pericarditis.
- Nursing Considerations: Administer with food or milk to minimize gastrointestinal (GI) upset. Monitor for GI bleeding (e.g., black, tarry stools; coffee-ground emesis). Advise patients to take with a full glass of water.
- Colchicine: An anti-inflammatory agent that works by inhibiting microtubule assembly, reducing inflammation. It is increasingly used as first-line therapy or in combination with NSAIDs, and is particularly effective in preventing recurrence.
- Nursing Considerations: Do not take with grapefruit juice as it increases colchicine toxicity (nausea, vomiting, abdominal pain, diarrhea). Can be taken with or without food. Monitor for GI side effects.
- Corticosteroids: Such as Prednisone. Reserved for patients who do not respond to NSAIDs/Colchicine, have contraindications to them, or have specific etiologies (e.g., autoimmune).
- Nursing Considerations: Administer with food. Monitor for side effects (e.g., hyperglycemia, increased infection risk, fluid retention, mood changes). Taper slowly to prevent rebound inflammation.
- IV Antibiotics: Administered if bacterial pericarditis is diagnosed or strongly suspected. Based on culture and sensitivity results.
Management for Moderate to Severe Pericarditis / Hospitalized Patients
These patients require more intensive monitoring and often invasive procedures.
Comprehensive Assessment:
- Establish Good Rapport: Essential for building trust and reducing patient anxiety.
- Detailed History Taking: Include smoking history, anginal pain characteristics (differentiate from pericardial pain), and other presenting symptoms.
- Continuous Observations: Monitor vital signs (temperature, pulse, respiration, blood pressure) frequently. Perform a thorough general examination, including cardiovascular, respiratory, and peripheral assessments.
Pain Management Intensified:
- Positioning: Continue to keep the patient in high Fowler’s position or encourage leaning forward to relieve pain.
- Pain Level Monitoring: Continuously monitor patient pain level using a standardized scale and evaluate the effectiveness of analgesics within 30 minutes of administration.
- Administer Prescribed Pain Medication: May include stronger analgesics such as morphine or other opioids if NSAIDs are insufficient.
Intensive Cardiac Monitoring:
- Monitor for Cardiac Tamponade: Hourly or more frequent assessment for signs of cardiac tamponade (pulsus paradoxus, JVD, muffled heart sounds, hypotension, tachycardia). Notify physician immediately if signs develop.
- Continuous ECG Monitoring: To detect arrhythmias or worsening ST-T changes.
Fluid Balance and Hemodynamic Support:
- Careful Maintenance of Fluid Intake and Output (I&O): Essential, especially if there's a risk of fluid overload or if diuretics are used.
- Daily Weight Check: To monitor for fluid retention.
- Administer O2: Maintain SpO2 >90% to optimize oxygen delivery to tissues.
- IV Antihypertensive Medication: If persistent blood pressure elevation is a concern (though hypotension is more common with tamponade).
Medication Administration and Monitoring:
- Administer NSAIDs and Steroids with Food: To reduce GI side effects.
- Ensure Timely Administration of Antibiotics: If bacterial infection is the cause.
Patient Education and Psychological Support:
- Disease Process Discussion: Explain pericarditis, its causes, and signs/symptoms. Reassure the patient that the chest pain is not a myocardial infarction (unless it is a co-existing condition).
- Anxiety Reduction: Build a strong rapport with the patient to reduce anxiety associated with chest pain and hospitalization.
- Preparation for Procedures: If surgical intervention (e.g., pericardiocentesis, pericardiectomy) is needed, provide psychological support and prepare the patient for the procedure.
- Post-Surgical Education: For post-surgical patients, discuss warning signs of postoperative complications such as fever, inflammation at the surgical site, bleeding, and excessive swelling.
- Activity Progression: Advise the patient to resume daily activities slowly and gradually to prevent symptom recurrence. Ensure bed rest until fever, chest pain, and friction rub disappear.
- Warning Signs for Home: Educate on when to seek medical attention after discharge (e.g., recurrent chest pain, fever, increasing shortness of breath, swelling).
Bowel and Bladder Care:
- Provide a Bedside Commode: To reduce stress on the heart during defecation, especially if patient is on strict bed rest.
- Assist with Bathing if Necessary: To conserve patient energy.
Monitoring for Specific Complications (less common but severe):
- Persistent Cough, Vomiting, or Systolic BP >180 mmHg: Closely monitor and notify physician immediately, as these may increase risk for specific complications (e.g., hemorrhage in aortic dissection if not carefully managed).
Nursing Interventions for Pericarditis
Nursing care for patients with pericarditis is crucial for symptom management, monitoring for complications, providing emotional support, and educating the patient and family. The following is a comprehensive list of nursing interventions:
- Pain Management and Comfort:
- Assess the patient’s pain level regularly using a standardized pain scale (e.g., 0-10) and document findings.
- Evaluate the effectiveness of administered analgesics (e.g., NSAIDs, aspirin, colchicine, opioids) within 30 minutes to 1 hour of administration.
- Administer prescribed pain medication promptly and on schedule to maintain comfort.
- Position the patient comfortably, typically in a high Fowler’s position (sitting upright) or leaning forward, as this position significantly alleviates pericardial chest pain. Avoid supine (lying flat) positioning.
- Provide non-pharmacological pain relief measures, such as guided imagery, distraction, or quiet environment, as appropriate.
- Vital Signs and Hemodynamic Monitoring:
- Monitor vital signs (temperature, pulse, respiration, blood pressure) frequently and continuously, especially during the acute phase or if complications are suspected.
- Continuously monitor the patient's electrocardiogram (ECG) for rhythm disturbances, ST-T wave changes, or PR segment depression characteristic of pericarditis.
- Assess for signs and symptoms of cardiac tamponade (e.g., muffled heart sounds, jugular venous distension [JVD] with clear lung sounds, hypotension, pulsus paradoxus [a significant drop in systolic BP during inspiration], tachycardia, narrowed pulse pressure) at least every 4-8 hours and as needed (PRN). Report any changes immediately to the physician.
- Monitor for signs of decreased cardiac output and perfusion (e.g., cool extremities, decreased urine output, altered mental status).
- Administer supplemental oxygen as prescribed to maintain oxygen saturation (SpO2) above 90% or as per target.
- Medication Administration and Monitoring:
- Administer all prescribed medications (e.g., NSAIDs, colchicine, corticosteroids, antibiotics) as ordered, ensuring correct dosage, route, and timing.
- Administer NSAIDs and corticosteroids with food or milk to minimize gastrointestinal irritation and reduce the risk of peptic ulcers.
- Educate the patient about each medication, its purpose, potential side effects, and the importance of adherence.
- Monitor for adverse effects of medications (e.g., GI bleeding with NSAIDs, hyperglycemia with corticosteroids, diarrhea with colchicine).
- If antibiotics are prescribed, ensure timely administration and monitor for signs of infection resolution.
- Fluid Balance and Nutritional Support:
- Maintain accurate intake and output (I&O) records, especially if the patient has a pericardial effusion or is receiving diuretics.
- Monitor daily weights to assess for fluid retention or dehydration.
- Encourage adequate oral fluid intake unless contraindicated.
- Provide a diet that is easily digestible and well-tolerated. Assist with feeding if the patient is too weak or fatigued.
- Activity and Rest:
- Ensure the patient has adequate bed rest during the acute inflammatory phase, usually until fever, chest pain, and pericardial friction rub have resolved.
- Assist the patient with activities of daily living (ADLs) as needed to conserve energy and reduce cardiac workload.
- Provide a bedside commode to reduce straining during bowel movements, which can increase intrathoracic pressure.
- Educate the patient on the importance of gradual resumption of physical activity after the acute phase, advising avoidance of strenuous activities for several weeks to months to prevent recurrence.
- Patient Education and Psychological Support:
- Explain the disease process of pericarditis, its causes, symptoms, and the rationale behind the treatment plan to the patient and family.
- Reassure the patient that the chest pain, although severe, is typically not indicative of a myocardial infarction (heart attack), which can alleviate significant anxiety.
- Build a trusting and empathetic rapport with the patient to reduce anxiety and promote open communication.
- Provide psychological support, acknowledging the patient's fears and concerns related to chest pain and their condition.
- If pericardiocentesis or other procedures are anticipated, explain the procedure clearly, address patient questions, and provide emotional support before, during, and after.
- For post-surgical patients (e.g., after pericardiectomy or creation of a pericardial window), educate on warning signs of postoperative complications such as fever, signs of infection at the surgical site, unusual bleeding, or excessive swelling.
- Educate the patient on warning signs of recurrence (e.g., return of chest pain, fever) and when to seek medical attention after discharge.
- Discuss the importance of medication adherence, follow-up appointments, and lifestyle modifications.
- Monitoring for Other Complications:
- Closely monitor for and report persistent cough, vomiting, or significant changes in blood pressure (e.g., systolic BP >180 mmHg), as these may indicate other underlying issues or increase the risk for certain complications.
- Assess for signs of chronic or constrictive pericarditis in patients with recurrent or persistent symptoms (e.g., persistent JVD, ascites, peripheral edema, Kussmaul's sign).
Nursing Diagnoses for Pericarditis
Nursing diagnoses provide a framework for nursing care, identifying patient problems that nurses can independently address. For pericarditis, these diagnoses often revolve around pain, inflammation, potential cardiac complications, and the psychological impact of the illness. Here are several common and relevant nursing diagnoses, with supporting evidence:
- Acute Pain related to inflammatory process of the pericardium as evidenced by:
- Verbalization of severe chest pain (e.g., "10 out of 10," sharp, stabbing, precordial pain radiating to neck/shoulder).
- Facial grimacing, guarding behavior (e.g., clutching chest), restlessness.
- Increased heart rate and blood pressure (unless in tamponade, where BP may drop).
- Pain exacerbated by deep breathing, coughing, lying supine, or movement.
- Pain relieved by leaning forward.
- Shortness of breath (due to pain and/or effusion).
Rationale: The hallmark of acute pericarditis is severe, often pleuritic, chest pain caused by the inflammation and irritation of the pericardial layers. This pain significantly impacts comfort and can trigger sympathetic responses.
- Hyperthermia related to inflammatory process (e.g., infection, autoimmune response) as evidenced by:
- Body temperature above normal range (e.g., 38.0°C or higher).
- Flushed skin, warm to touch.
- Increased heart rate and respiratory rate.
- Profuse sweating and/or chills.
- Malaise and generalized weakness.
Rationale: Inflammation, particularly if infectious (e.g., bacterial, viral), often leads to a systemic febrile response as the body attempts to combat the underlying cause and inflammatory mediators are released.
- Decreased Cardiac Output related to impaired ventricular filling due to pericardial inflammation and/or effusion as evidenced by:
- Fatigue, weakness, and generalized malaise.
- Inability to perform usual Activities of Daily Living (ADLs) or requiring increased rest.
- Shortness of breath, dyspnea on exertion, or orthopnea.
- Tachycardia (compensatory mechanism).
- Hypotension (especially with significant effusion/tamponade).
- Weak or thready peripheral pulses.
- Cool, clammy skin.
- Delayed capillary refill.
- Decreased urine output.
- Altered mental status (in severe cases).
- Abnormal hemodynamic readings (e.g., low cardiac index, elevated central venous pressure).
Rationale: Inflammation of the pericardium can lead to fluid accumulation (effusion) or thickening/constriction, both of which can impede the heart's ability to fill adequately, thereby reducing the amount of blood pumped out to the body.
- Activity Intolerance related to acute chest pain, decreased cardiac output, and systemic inflammation as evidenced by:
- Verbalization of fatigue, tiredness, or weakness after minimal exertion.
- Dyspnea on exertion.
- Disinterest or inability to participate in activities of daily living (ADLs) due to pain or fatigue.
- Reported need for increased rest periods.
- Changes in vital signs (e.g., increased heart rate, respiratory rate, or blood pressure) with activity.
Rationale: The pain associated with pericarditis makes movement difficult, and the systemic inflammatory response, coupled with potentially decreased cardiac output, reduces the patient's physiological reserve for physical activity.
- Excessive anxiety related to chest pain of unknown etiology (initially), fear of serious cardiac event (e.g., heart attack), or threat to health status as evidenced by:
- Verbalization of feeling nervous, fearful, worried, or helpless.
- Increased heart rate and respiratory rate (beyond that caused by pain/fever).
- Restlessness, agitation, or irritability.
- Crying or tearfulness.
- Sleep disturbances.
- Questioning about the prognosis or cause of illness.
- Preoccupation with symptoms.
Rationale: Chest pain is often associated with myocardial infarction, leading to significant anxiety for patients. The uncertainty of the diagnosis, the severity of symptoms, and the potential for complications can further exacerbate anxiety.
- Risk for Ineffective Health Management related to insufficient knowledge of the disease process, treatment regimen, and potential for recurrence as evidenced by:
- (No subjective/objective data yet, as it's a risk diagnosis, but factors include:)
- Lack of previous experience with pericarditis.
- Complex medication regimen (e.g., multiple anti-inflammatory drugs).
- Need for activity restrictions.
- Potential for recurrent episodes.
Rationale: Patients need comprehensive education on their condition, medications, symptom recognition, and activity modifications to prevent recurrence and manage the disease effectively post-discharge.
- Risk for Fluid Volume Deficit (in specific cases, e.g., if experiencing excessive sweating due to fever and inadequate fluid intake, or with aggressive diuretic therapy) related to:
- Fever-induced diaphoresis.
- Nausea/vomiting impacting oral intake.
- Aggressive diuretic therapy for effusion management.
Rationale: While fluid overload is a concern with effusions, certain interventions or symptoms can lead to dehydration, necessitating careful fluid balance monitoring.
- Risk for Impaired Gas Exchange (in cases of significant pericardial effusion leading to lung compression or severe cardiac compromise) related to:
- Decreased lung expansion due to large pericardial effusion.
- Reduced cardiac output impacting pulmonary perfusion.
Rationale: While not a primary diagnosis for all pericarditis, a very large effusion can restrict lung expansion, and severe cardiac compromise can lead to ventilation-perfusion mismatch.
- Risk for Infection (post-procedural) related to invasive procedures (e.g., pericardiocentesis, pericardiectomy) as evidenced by:
- Presence of surgical incision or puncture site.
- Disruption of skin integrity.
- Invasive lines (e.g., IV, drain).
Rationale: Any break in skin integrity or invasive procedure introduces a risk of localized or systemic infection.
Complications of Pericarditis
While most cases of acute pericarditis are benign and self-limiting, complications can occur, ranging from mild to life-threatening.
- Pericardial Effusion:
- Description: Accumulation of excess fluid within the pericardial sac. It is a common complication.
- Severity: Can range from small and asymptomatic to large and rapidly accumulating, which can lead to cardiac tamponade.
- Cardiac Tamponade:
- Description: A medical emergency where a large or rapidly accumulating pericardial effusion compresses the heart, severely restricting its ability to fill with blood during diastole.
- Consequences: Leads to a significant decrease in cardiac output, hypotension, and shock if not treated promptly.
- Treatment: Requires urgent pericardiocentesis (fluid drainage) or surgical drainage.
- Recurrent Pericarditis:
- Description: Episodes of pericarditis that recur after a symptom-free interval following an initial acute episode. This can be very distressing for patients.
- Management: Often requires long-term anti-inflammatory therapy, sometimes with colchicine.
- Chronic Pericarditis:
- Description: Pericarditis that persists for more than 3 months. Can lead to thickening and fibrosis of the pericardium.
- Constrictive Pericarditis:
- Description: A severe, long-term complication where the pericardium becomes thick, rigid, and fibrotic, preventing the heart from filling properly.
- Consequences: Leads to symptoms of right-sided heart failure (e.g., severe peripheral edema, ascites, elevated JVD) and can be progressive.
- Treatment: Often requires surgical pericardiectomy (removal of the pericardium).
- Myocarditis (Myopericarditis):
- Description: Inflammation of the heart muscle occurring concurrently with pericarditis.
- Consequences: Can lead to myocardial dysfunction, arrhythmias, and elevated cardiac biomarkers (e.g., troponin).
- Fatal Hemorrhage:
- Context: This is a very rare but catastrophic complication, typically associated with traumatic pericardial injury, iatrogenic injury during procedures (e.g., central line insertion, pericardiocentesis), or rupture of a large vessel (e.g., aortic dissection) into the pericardial sac.
- Stroke and Paraplegia due to Interruption of the Anterior Spinal Artery, Abdominal Ischemia:
- Context: These are not direct complications of typical pericarditis. They are severe complications specifically associated with Aortic Dissection, especially if it involves the great vessels originating from the aorta or compromises blood supply to the spinal cord or abdominal organs. If an aortic dissection leads to hemopericardium, it can mimic pericarditis. It's crucial to differentiate these conditions due to the vastly different prognoses and emergency management required for aortic dissection.
