Exhibits

Click to highlight the findings that require follow up.

Neurological: Alert and oriented person, place, time, and situation Agitated. Denies headaches.

Cardiovascular: Reported chest pain described as pressure and tightness that is unrelieved with rest. Rapid regular rhythm. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.

Respiratory: Rapid and shallow breaths. Clear breath sounds throughout bilateral lungs.

Gastrointestinal: Within normal limits (WNL).

Genitourinary: WNL.

Musculoskeletal M/MIL

Pain: Reported 7 on a 0 to 10 scale, tightness and pressure in chest. Started approximately 2 hours ago and got progressively worse, unrelieved by rest.

A. Evaluate complete blood cell counts: While baseline labs, including CBC, are useful, they are not the immediate priority before a pericardiocentesis. These values provide general health data but do not guide acute decision-making for cardiac tamponade.

B. Assess for paradoxical pulse: A paradoxical pulse an exaggerated drop in systolic blood pressure during inspiration is a hallmark sign of cardiac tamponade. Recognizing this finding helps confirm clinical suspicion and prioritize urgent intervention.

C. Discontinue anticoagulants: Stopping anticoagulants is important to prevent bleeding during the procedure, this must be done under provider guidance and may not be feasible if the situation is emergent. It is a safety consideration but not the most urgent nursing action.

D. Monitor central venous pressure (CVP): CVP monitoring can reflect rising intrapericardial pressure in tamponade but often requires invasive access and may not be immediately available. It provides supportive data, but clinical signs such as paradoxical pulse offer more immediate diagnostic relevance.

A. A description of the chest pain when client is at rest: Determining whether the pain occurs at rest helps differentiate stable from unstable angina. Stable angina typically resolves with rest and is exertion-related, while pain at rest may suggest unstable angina.

B. A demonstration of the activity that precipitates pain: While understanding what provokes the pain is helpful, a physical demonstration is unnecessary and potentially dangerous, especially if it might trigger another anginal episode.

C. A complete seven (7) day diet history of client's oral intake: Dietary intake is not immediately relevant for evaluating recent angina symptoms. Priority should be placed on identifying acute features that may signal unstable angina or myocardial infarction.

D. The client’s blood pressures sitting and standing: Assessing for orthostatic hypotension is useful in evaluating dizziness or syncope but does not directly address the nature or severity of chest pain. It is not the priority assessment for symptoms of angina pectoris following exertion.