Pericarditis

Pericarditis
Definition:
Pericarditis refers to an inflammation of the pericardium, the membranous sac enveloping the heart. It may be a primary illness, or it may develop in the course of a variety of medical and surgical disorders.
Pericarditis may be acute or chronic. It may be classified by the layers of the pericardium becoming attached to each other (adhesive) or by what accumulates in the pericardial sac: serum (serous), pus (purulent), calcium deposits (calcific), clotting proteins (fibrinous), or blood (sanguinous).

Causes:
 Pericarditis occurs after pericardectomy (opening of the pericardium) in 5% to 30% of patients after cardiac surgery.
 Pericarditis that occurs within 10 days to 2 months after acute myocardial infarction (Dressler’s syndrome) causes 1% to 3% of all cases of pericarditis.
• Idiopathic or nonspecific causes.
• Infection: usually viral (eg, Coxsackie, influenza); rarely bacterial (eg, streptococci, staphylococci, meningococci, gonococci); and mycotic (fungal).
• Disorders of connective tissue: systemic lupus erythematosus, rheumatic fever, rheumatoid arthritis, polyarteritis.
• Hypersensitivity states: immune reactions, medication reactions, serum sickness.
• Disorders of adjacent structures: myocardial infarction, dissecting aneurysm, pleural and pulmonary disease (pneumonia).
• Neoplastic disease: caused by metastasis from lung cancer or breast cancer, leukemia, and primary (mesothelioma) neoplasms.
• Radiation therapy.
• Trauma: chest injury, cardiac surgery, cardiac catheterization, pacemaker implantation.
• Renal failure and uremia.
• Tuberculosis.

Pathophysiology/Etiology:
Pericarditis can lead to an accumulation of fluid in the pericardial sac (pericardial effusion) and increased pressure on the heart, leading to cardiac tamponade. Frequent or prolonged episodes of pericarditis may also lead to thickening and decreased elasticity that restricts the heart’s ability to fill properly with blood (constrictive pericarditis). The pericardium may become calcified, further restricting ventricular expansion during ventricular filling (diastole). With less filling, the ventricles pump out less blood, leading to decreased cardiac output and signs and symptoms of heart failure. Restricted diastolic filling may result in increased systemic venous pressure, causing peripheral edema and hepatic failure.


Clinical Manifestations
The most characteristic symptom of pericarditis is:
 Chest pain, although pain also may be located beneath the clavicle, in the neck, or in the left scapula region. The pain or discomfort usually remains fairly constant, but it may worsen with deep inspiration and when lying down or turning. And may be relieved with a forward leaning or sitting position.
 Frictions rub (creaking sound occurring in the presence of pericardial inflammation).
 Dyspnea—from compression of heart and surrounding thoracic structures.
 Fever, sweating, chills—due to inflammation of pericardium.


Diagnostic Evaluation
1. Echocardiogram—most sensitive method for detecting pericardial effusion.
2. Chest x-ray—may show heart enlargement.
3. ECG— detects ST changes in many, if not all, leads.
4. WBC and differential elevations indicating infection.
5. Increased erythrocyte sedimentation rate (ESR).
Management
To Management the disease should determine the cause, administer therapy, and be alert for cardiac tamponade.
 When cardiac output is impaired, the patient is placed on bed rest until the fever, chest pain, and friction rub have subsided.
 Analgesics and NSAIDs such as aspirin or ibuprofen may be prescribed for pain relief during the acute phase.
 Hasten the reabsorption of fluid in the patient with rheumatic pericarditis.
 Corticosteroids (eg, prednisone) may be prescribed if the pericarditis is severe or if the patient does not respond to NSAIDs. Colchicine may also be used as an alternative medication.
 Pericardiocentesis, a procedure in which some of the pericardial fluid is removed, may be performed to assist in the identification of the causative agent.
 Surgical removal of the tough encasing pericardium (pericardiectomy) may be necessary to release both ventricles from the constrictive and restrictive inflammation.

Complications
 Cardiac tamponade
 Congestive heart failure
 Hemopericardium (especially patients post-MI receiving banticoagulants)


Nursing process
Nursing Assessment
 Pain management with analgesics, positioning, and psychological support.
 Educates and assists the patient with activity restrictions until the pain and fever subside.
 Encourages the patient’s condition improves; gradual increases of activity.
 Educates the patient and family about a healthy lifestyle to enhance the patient’s immune system.
 Monitors the patient for heart failure. A patient who is hemodynamically unstable or experiencing congestion is treated the same as a patient with acute heart failure.