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학습 자료 둘러보기 →In a patient with superior vena cava syndrome presenting with dyspnea and venous distention, the nurse must immediately assess for cardiac tamponade. The most critical finding is muffled heart sounds with pulsus paradoxus greater than 20 mmHg, indicating severely compromised cardiac output.
Pulsus paradoxus is measured by noting the difference in systolic pressure between expiration and the first audible Korotkoff sound during inspiration. A drop exceeding 10 mmHg is abnormal; a finding over 20 mmHg is a hallmark of life-threatening tamponade physiology.
Do not confuse pulsus paradoxus with a simple drop in blood pressure. It is a specific exaggeration of the normal inspiratory pressure decline. Hypotension and weak pulses are late, pre-arrest signs; identifying the pulsus paradoxus allows for earlier intervention.
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