1450 -

• Client was admitted directly from the primary healthcare physician's office for a severe exacerbation of systemic lupus erythematosus (SLE).
• The client was being treated outpatient with corticosteroids but was not responding.
• Reported intermittent chest pain at the physician's office and became pale and diaphoretic.
• The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations.
• The client was directly admitted to the intensive care unit for observation and medical management.
• Cardiac consultation has been placed, and laboratory work is pending.
• The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension

1629 – Client's spouse alerted RN to the client reporting chest pain. On assessment, the client had a Glasgow coma scale of 15 and was pale on assessment. A butterfly-shaped rash across the cheeks and bridge of the nose. Clear lung fields bilaterally, muffled heart sounds. Radial peripheral pulses 2+. Client stated, "my chest hurts." Cardiac monitor showed sinus tachycardia with a rate of 119. + Jugular venous distention at 90 degrees. T 100° F (37.8° C) RR 25, P 119, BP 105/89. Pulse oximetry 95% on room air. An immediate 12-lead electrocardiogram (ECG) was obtained and showed sinus tachycardia with no ST-segment changes.

1450 -

• Admit to intensive care unit (ICU)
• Continuous cardiac monitoring
• Consultation with cardiology
• Chest radiograph (x-ray)
• Establish peripheral vascular access device

Chest radiograph (x-ray)

1635: Pericardial effusion with cardiomegaly. Enlarged cardiac silhouette. No lung abnormalities.

1710 - Emergent bedside pericardiocentesis was performed because of the client's deteriorating hemodynamic status. 100 mL of pericardial fluid was aspirated. Post-procedure vital signs stabilized.