TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

CARDIAC TAMPONADE

BY: KRISIANNE MAE L. FRANCISCO

BSN 4B (GROUP 4)
 TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

DAILY PHYSICAL EXAMINATION REPORT

Name of Patient: __________________________ Age: ________Date of Birth: ______________
Medical Diagnosis: _______________________ Nursing Diagnosis: ________________________
Assessed by: _____________________ Date of Assessment: ______________ Time: _____

Assessme
Area nt Description of Findings & Interpretation
N AbN
General Appearance The patient is lying down.
Posture /
Hygiene/Grooming
Nutrition/Diet
Body Size/Habitus
Height: ________
Weight: _______
Supply appropriate data:
 IBW: ___________
 BMI: ___________
 IRS: ____________
Behavior
LOC The patient is in the ICU, and he is unconscious.
/
Vital Signs
Temperature: _36.9
℃______
Pulse Rate: 96 cpm
Rhythm:
Respiration Rate: 23bpm Tachypneic
Rhythm: /
___________
Blood Pressure: 76/44 Hypotensive
mmHg /
Skin The patient is pale due to low blood pressure.
Color /
Temperature The patient is slightly cold due to impaired blood
/ circulation in the body.
Turgor
 Texture
Integrity
Unusual Marks
Rashes, Lesions
Pressure sore: Yes ___ No
Site:
___________________
Edema: Yes ____ No ____ A pitting bipedal edema was noted due to impaired renal
Site: _______ / function.
Type: _____
Size/Degree: _____
Hair
Texture
Thickness
Color & Distribution
Hygiene Status
Nails Presence of bluish discoloration in the fingers or cyanosis.
Color & Shape /
Hygiene Status
Presence of Clubbing
Head
Shape & Symmetry
Unusual swelling
Cranial bruit

Form No.: TSU-COS-

Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 6
SF-

Assessme
Area nt Description of Findings & Interpretation
N AbN
Eyes
Size, placement &
alignment
Cornea
Pupils
 Size (mm)
PERRLA
Visual Acuity
Orbital Bruit
Other Findings:
________________
Ear
Location/Alignment
Pinna, Cannals, Drums
Hygiene
 Discharge and Odor
Hearing Acuity
Tinnitus
Vertigo/Dizziness
Other Findings: ______
Nose
Shape
Symmetry
Patency
Mucosal Integrity
Epistaxis
Sinuses
Other Findings: ______
Lips
Integrity
Symmetry
Color Pale color of the lips.
/
Other Findings: _
Mouth
Hygiene
Number & Condition of Teeth
Gums
Mucosal Integrity
Tongue
Tonsils
Palate
Parotid Gland
Hoarseness
Other Findings: Tracheostomy tube was inserted.
/
Neck
Carotid Bruit
Neck Veins Jugular veins are distended up to nearly 5 cm above
/ the sternal angle.
Thyroid
Trachea
Rigidity/Tenderness
Mass/Bruises
Other Findings:_______
Chest and Lungs
Shape & Symmetry
 Nipple & Areola
 Mass/Lump
 Others:__________
 Effectivity Date: June 22,
Form No.: TSU-COS-SF- Revision No.: 00 Page 2 of 6
2016

Assessment
Area N AbN Description of Findings & Interpretation
Chest and Lungs
Breathing
 Spontaneity Mild respiratory distress with diminished breath
/ sounds on the base of the right lung.
 With Ventilator
 With Tracheostomy Tracheostomy tube was inserted.
/
 Rhythm Tachypneic
/
 Depth
 Effort
Use of Accessory Muscles
a. Intercostals
b. Abdominal
c. Sternocleidomastoid
d. Trapezius
Cough
Sputum Production: Yes __ No:
__
 Amount: _____________
 Consistency: __________
 Color: _______________
 Odor: _______________
Chest X-ray Result
Breath Sound (Specify)
a. Bronchial
b. Crackles
c. Rhonci
d. Wheezes
e. Stridor
f. Crepitus
CTT
Location: __________
Suction: ___________
Water Level: _______
Quality of Drainage:
___________
ABG
Other Findings:
________________
Heart
History
With Palpitation
Dyspnea
Rhythm
Point of Maximal Impulsec(PMI)
(PMI is felt at 5th ICS at apex
of heart) Specify:
a. Heaves
b. Clicks
c. Splitting
d. Thrills
e. Callops
f. Muffles
Presence of Heart Sounds
a. S1
b. S2
c. S3

Murmurs
a. Systolic
b. Diastolic

Form No.: TSU-COS- Revision No.: Effectivity Date: June 22,

Page 3 of 6
SF- 00 2016

Assessment
Area N AbN Description of Findings & Interpretation
Abdomen
Diet: ____________________
Mode of Feeding: __________
Shape and Symmetry
Umbilicus Protrusion
Bowel Sound (Indicate Sound)
 LUQ: __________
 RUQ: __________
 LLQ: __________
 RLQ: __________
Abdominal Bruit
Distention
Ascites: Yes: ____ No: ____
Nausea
Vomitus/Hematemesis
Amount: _______________
 Consistency: ____________
Color: _________________
Odor: _________________
Frequency: _____________
Drainage Tube
Abdominal Mass
Abdominal Girth: __________
Other Findings:
________________
Back
 Spine
 Paralumbar
Other Findings:
________________
Genitalia
Symmetry
Presence of Tenderness
Urethral Discharge
Bleeding
Pelvic Pain
LMP: ________________
With Dysuria
With Flank Pain
Nocturia
History of Urinary Stone
History of Impotence
With Urinary Catheter Decreased urine output 14ml/hr.
/
Urinalysis Finding:
_____________
Peritoneal Dialysis (PD)
a. Date Started
b. Incorporation
c. Cycle Exchange
Amount: _______________
Dwell Time: ____________
Drainage Time: __________
d. PD Return
Color: __________
Flow: __________

Hemodialysis
Frequency:
________________
Last HD:
__________________
Amount of Fluid Removed:
_____
Next HD:
__________________
Place:
____________________
Form No.: TSU-COS- Revision No.: Effectivity Date: June 22,
Page 4 of 6
SF- 00 2016

Assessme
Area nt Description of Findings & Interpretation
N AbN
Rectal Examination
Anal Inspection
With Hemorrhoids: Yes:__
No:__
Location: ______________
Characteristics: _________
Mass
Last Bowel Movement:
_________
Characteristic of Stool:
__________
Other Findings:
________________
Nodes
Lymphadenopathy
Location
a. Cervical R ___ L ___
b. Axillary
c. Inguinal R ___ L ___
Others ______________
Extremity
Texture
Capillary Refill Capillary refill less than 3 seconds.
/
Peripheral Pulse (both sides)
 Carotid
 Radial
 Ulna
 Brachial
 Femoral
 Posterior Tibial
 Dorsalis Pedis
 Popliteal

Clubbing of Fingers
Varicosities
 Thrombophlebitis
Cyanosis Cyanotic nails and oral mucosa
/
Joints
 Erythema
 Tenderness
 Deformity
 Swelling
Muscles
 Bulk
 Tone
 Tenderness
Ulcerations
Edema Presence of bipedal pitting edema
/
Other Findings: Deep venous thrombosis in both legs
________________ /

Form No.: TSU-COS- Revision No.: Effectivity Date: June 22,

Page 5 of 6
SF- 00 2016

Assessme
Area nt Description of Findings & Interpretation
N AbN
Hematopoietic
Easy Bruisability
Excessive Bleeding
Anticoagulants
Bleeding Profile
Anemia
Hematology Report
Other Findings:
________________
Neurology
Assessment of Cranial Nerves
 CN I (Olfactory)
 CN II (Optic)
 CN III (Oculomotor)
 CN IV (Trochlear)
 CN V (Trigeminal)
 CN VI (Abducens)
 CN VII (Facial)
 CN VIII (Vestibulocochlear)
 CN IX (Glossopharyngeal)
 CN X (Vagus)
 CN XI (Spinal Accessory)
 CN XII (Hypoglossal)

Motor and Posture Impaired motor function of the lower extremities or

/ paraplegia.
Sensory Perception Impaired sensory function of the lower extremities or
/ paraplegia.
Reflexes
a. Indicate Type of Reflex______
________________________
b. Pathologic Reflex: Yes__
No__
Other Findings:
_________________
Patient’s ADL The patient was unable to perform his ADLs because
a. Bathing he is unconscious.
b. Dressing
c. Elimination /
d. Mobility and Movement
e. Nutrition and Feeding

Form No.: TSU-COS-SF- Revision No.: 00 Effectivity Date: June 22, 2016 Page 6 of 6
 TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Excess fluid volume After 8 hours of nursing Independent After 8 hours of nursing
The patient suddenly related to impaired interventions, the client  Monitor vital  to determine intervention, the clients
stopped breathing. cardiac contraction. will maintain adequate signs regularly. changes in the verbalized improved fluid
fluid volume as patient’s volume as evidenced by:
Objective: evidenced by increased condition.
 GCS: 3 urine output to 30mL/hr., - Increased urine
 Paraplegia absence of edema and  Monitor client’s  To note changes output from 14
 Cyanosis normal vital signs. intake and output. in renal status. into 19mL/hr
 Jugular veins are
distended up to - Decreased pitting
nearly 5 cm above  Elevate the head  This position edema from grade
the sternal angle of the bed. facilitates optimal 2+ into grade 1+
 Slow capillary ventilation, and it bipedal edema.
refill less than 3 may also help to - Increased blood
seconds regulate blood pressure from
 Grade 2+ bipedal circulation in the 76/44 into 80/60
pitting edema body. mmHg
 Deep venous - Normal
thrombosis on  Provide warm  To manage respiratory rate 20
both legs tepid sponge bath. veinous dilation bpm
 Decreased urine and improve
output 14ml/hr. blood circulation.
Vital Signs:
Temperature: 36.9 ℃  Frequently change  Repositioning
Pulse Rate: 96 cpm the client’s promotes
Respiration Rate: 23bpm position at least enhanced
Blood Pressure: 76/44 every 2 hours. breathing,
mmHg decreases pressure
ulcer and
mobilization of
secretions.

 Slightly elevate  To manage the

the feet of the edema.
patient using 2
pillows

Dependent  Diuretics decrease

 Administer plasma volume
diuretics (e.g., and peripheral
furosemide) as edema.
indicated.
 Oxygen is
 Provide oxygen administered to
therapy as increase the
indicated. amount of oxygen
carried by
available
hemoglobin in the
blood.

 Administer IV
fluids as ordered.  Sufficient fluid
intake maintains
adequate filling
pressures and
 optimizes cardiac
output needed for
tissue perfusion.
 Administer
medications as  Medication
prescribed. therapy is more
effective when
initiated early.
 TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

SOAPIE CHARTING

S - The patient suddenly stopped breathing.

O - GCS: 3
- Jugular veins are distended up to nearly 5 cm above the sternal angle

- Slow capillary refill less than 3 seconds

- Grade 2+ bipedal pitting edema

- Deep venous thrombosis on both legs

- Decreased urine output 14ml/hr.

Vital Signs:

- Temperature: 36.9 ℃

- Pulse Rate: 96 cpm

- Respiration Rate: 23bpm

- Blood Pressure: 76/44 mmHg

A - Excess fluid volume related to impaired cardiac contraction.

P - After 8 hours of nursing interventions, the client will maintain adequate fluid volume as
evidenced by increased urine output to 30mL/hr., absence of edema and normal vital signs.
I
 Done monitoring vital signs regularly.
 Done monitoring client’s intake and output.
 Elevated the head of the bed.
 Provided warm tepid sponge bath.
 Frequently changed the client’s position at least every 2 hours.
 Slightly elevated the feet of the patient using 2 pillows.
 Maintained mechanical ventilation.
 Maintained central venous catheter.
  Maintained intravenous fluid.
 Administered medication as prescribed.

E - After 8 hours of nursing intervention, the clients verbalized improved fluid volume as
evidenced by:

- Increased urine output from 14 into 19mL/hr

- Decreased pitting edema from grade 2+ into grade 1+ bipedal edema.

- Increased blood pressure from 76/44 into 80/60 mmHg

- Normal respiratory rate 20 bpm

 TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

PATIENT EDUCATION FORM

Name Francisco, Krisianne Mae L. Area

Inclusive
Year Level RLE Group dates of
Rotation
Name of
Patien B Age 57 y/o Gender Male
Patient
Date
Diagnosis Excess Fluid Volume
Admitted

MAIN CONCEPT / TOPIC:

Details of Patient Education Content:

FAMILY HEALTH TEACHING

- Demonstrate how to elevate the head of the bed to the significant

others and explain the importance of this intervention which is to
help the regulation of blood circulation and enhance ventilation of
the patient.
- Demonstrate to the significant others the frequent changing of
the client’s position to prevent pressure ulcer formation.
- Explain to the client the possible complications and report
immediately if they noticed.
- Explain to the client together with the physician the importance
and benefits of medical procedures and interventions.

Patient’s Signature / Significant Other’s Signature

Date Signed
Date Submitted

Form No.: TSU-COS-SF-09 Revision No.: 00 Effectivity Date: June 22, 2016 Page 1 of 1