8.3 Cardiovascular Symptoms

Circulation problems in serious illness

Cardiovascular symptoms on CHPN are less about reading an electrocardiogram strip and more about matching the tool to the trajectory. Heart failure edema, malignant pericardial effusion, ischemic limbs, and the slowing circulation of active dying can look similar if you only watch the blood pressure number. The nursing question is always: will this intervention reduce distress that the patient can feel, or are we treating a number that no longer represents a reversible life?

Edema and lymphedema

Dependent edema is pitting swelling of legs, sacrum, or scrotum from heart failure, hypoalbuminemia, venous stasis, or drugs such as dihydropyridine calcium-channel blockers and corticosteroids. First comfort measures are elevation, loose clothing, meticulous skin care (moisture, no vigorous rubbing, watch for tears), and compression only if arterial supply is adequate and the skin can tolerate it. Loop diuretics help when the kidneys still respond and when extra volume is driving dyspnea or painful tense edema. They fail—and they cause bladder urgency and electrolyte chaos—when the patient is dying, albumin is gone, or the swelling is lymphedema.

Lymphedema is protein-rich swelling after lymph-node dissection or radiation, often unilateral and doughy. Primary therapy is complete decongestive care: compression, elevation, skin hygiene, and specialist physical therapy when available. Do not use a diuretic as first-line lymphedema treatment. Exam trap: a unilateral arm after axillary surgery is not "heart failure needing furosemide."

Scrotal and genital edema need support garments or towels, antifungal care in skin folds, and dignity-preserving draping. Families often ask for "water pills" because swelling looks like suffering. Teach that stretching skin can be uncomfortable, but drying someone out who can no longer eat or drink does not restore a normal ankle.

Ischemic pain

Myocardial ischemia and critical limb ischemia produce severe pain. In a patient who still wants hospital-level reversal, nitrates, antiplatelet therapy, and revascularization follow cardiology pathways. In hospice, opioids are first-line for rest ischemia. Nitrates remain reasonable if they still cut pain and blood pressure allows. Do not send a comfort-focused patient to the catheterization laboratory because the stem mentions chest pressure. Position, warmth of the room (not heating pads on ischemic skin), and wound care for arterial ulcers complete the plan. Resting an ischemic leg lower than the heart may ease arterial pain; elevation that helps venous edema can worsen arterial pain—believe the patient's report.

Pericardial tamponade: recognize, then branch on goals

Pericardial tamponade is impaired filling because fluid in the pericardial sac compresses the heart. Classic findings (Beck triad) are hypotension, jugular venous distention, and muffled heart sounds. Add pulsus paradoxus and, on a monitor, electrical alternans. Lung or breast cancer and metastases are familiar hospice contexts. Recognition matters even if you will not reverse it: a still-full-code palliative patient with sudden shock and muffled sounds may need emergency pericardiocentesis and transfer. A comfort-only patient with a known malignant effusion who is dying does not benefit from a futile needle in the last hours. Treat air hunger and anxiety, keep the family informed, and avoid an ambulance ride that cannot change the outcome. CHPN tests whether you can name the emergency and then not automatically activate it against stated goals.

Arrhythmia at the end of life

Atrial fibrillation with rapid rate, premature beats, and finally agonal bradycardia appear as death nears. Treat a symptomatic tachyarrhythmia only if the patient is distressed and the treatment still matches goals (rate control that eases palpitations or ischemia). As dying progresses, the pulse slows and becomes irregular; that is physiology, not a missed code. Pacemaker spikes on a monitor do not mean the person is "being kept alive against nature" in the same distressing way defibrillator shocks are. Do not start a full advanced-cardiac-life-support algorithm on a hospice patient whose plan is comfort unless the family and documents say otherwise and the event is truly unexpected.

Hypotension of dying

Cool, mottled extremities, thready pulse, and a falling systolic pressure are expected in active dying. Intravenous fluid boluses often produce pulmonary edema without restoring cognition or blood pressure. Vasopressors belong to intensive care, not to home hospice. Teach families that low blood pressure is a sign of shutting down, not a sign that the nurse "let them go." Offer mouth care, position for comfort, and stop blood-pressure checks that only generate panic.

Sequential compression devices and implantable defibrillators (brief)

Sequential compression devices (SCDs) for venous prophylaxis become noise, heat, and sleep disruption when the patient is dying and will not live long enough for a clot-prevention benefit to matter. Discontinue them when they no longer serve a goal the patient can feel.

An implantable cardioverter-defibrillator (ICD) can fire as the heart fails, producing painful shocks during dying. Deactivate the shocking function before that phase (magnet as a temporary field measure; formal deactivation by the device clinic as the plan). Pacemakers are generally left in place; they do not typically cause the same dying-phase trauma as shocks. This device conversation is covered in depth with goals-of-care content; here the symptom point is: prevent iatrogenic pain from the machine.

Treat versus comfort

A CHPN stem that reports a systolic pressure of 70 with mottling in the last hours is testing nonmaleficence, not your ability to quote a mean arterial pressure target.