9.2 Cardiovascular Alterations
Key Takeaways
Left-sided heart failure causes pulmonary symptoms; right-sided causes systemic congestion
Atrial fibrillation pools blood and raises stroke risk, so anticoagulation is essential
Arterial insufficiency: diminished pulses, pale cool skin, pain worse with elevation
Venous insufficiency: present pulses, brown edema, pain worse when dependent
Early shock shows tachycardia and restlessness before blood pressure ever drops
Cardiovascular Alterations
Cardiac items reward pattern recognition: left versus right, arterial versus venous, early versus late shock. The exam wants the LPN/VN to assess, intervene within scope, and report the right finding to the RN/provider at the right time.
Heart Failure
Heart failure is the inability to pump enough blood to meet metabolic demand. Localize it by where blood backs up.
| Type | Mechanism | Hallmark findings |
|---|---|---|
| Left-sided (most common) | Left ventricle fails; blood backs into lungs | Dyspnea, orthopnea, paroxysmal nocturnal dyspnea, crackles, pink frothy sputum |
| Right-sided | Right ventricle fails; blood backs into systemic veins | Jugular venous distention, dependent peripheral edema, hepatomegaly, ascites, weight gain |
| Systolic (HFrEF) | Ejection fraction <40% | Weak contraction, low output, fatigue |
| Diastolic (HFpEF) | Stiff ventricle, normal EF | Impaired filling, congestion despite normal EF |
Management essentials: daily weights at the same time on the same scale (report gain >2–3 lb/day), strict I&O, sodium restriction (often <2,000 mg/day), semi-Fowler's to reduce preload, oxygen, and meds — loop diuretics, ACE inhibitors/ARBs, beta blockers, and digoxin. Digoxin trap: hold and report if apical pulse <60, or if the patient has nausea, anorexia, yellow-green halos, or visual changes (toxicity, especially with hypokalemia). Therapeutic digoxin level is 0.5–2.0 ng/mL.
Angina vs. Myocardial Infarction
| Feature | Stable angina | Unstable angina | Myocardial infarction |
|---|---|---|---|
| Trigger | Predictable exertion | At rest, escalating | Often at rest |
| Duration | <5 min | >15 min | >30 min |
| Nitroglycerin relief | Yes | Partial/none | None |
| Troponin | Negative | Usually negative | Elevated |
MI presentation: crushing substernal pressure radiating to the left arm/jaw/back, diaphoresis, nausea, dyspnea, and impending doom. Atypical presentations (women, older adults, diabetics) show fatigue, indigestion, or back pain — a classic NCLEX trap. Initial care follows MONA: Morphine, Oxygen if SpO₂ <94%, Nitroglycerin (hold if systolic BP <90 or recent erectile-dysfunction drug), Aspirin (chewed 162–325 mg). Sublingual nitroglycerin: one tablet every 5 minutes up to three doses; call 911 if pain persists.
Arrhythmias
| Rhythm | Recognition | Significance |
|---|---|---|
| Sinus bradycardia | HR <60, regular | Concerning only if symptomatic |
| Sinus tachycardia | HR >100, regular | Reaction to fever, pain, hypovolemia |
| Atrial fibrillation | Irregularly irregular, no P waves | Clot/stroke risk — anticoagulate |
| Ventricular tachycardia | Wide QRS, rate >100 | Emergency if sustained/pulseless |
| Ventricular fibrillation | Chaotic, no organized rhythm | Cardiac arrest — defibrillate |
| Asystole | Flat line | Cardiac arrest — CPR + epinephrine |
Atrial fibrillation lets blood pool in the quivering atria, forming clots that embolize to the brain. Management = rate control (beta blockers, diltiazem, digoxin) plus anticoagulation (warfarin or a direct oral anticoagulant) to prevent stroke.
Arterial vs. Venous Insufficiency
| Feature | Arterial | Venous |
|---|---|---|
| Pain | Intermittent claudication, rest pain | Aching, heaviness |
| Skin | Pale, shiny, cool, hairless | Brown discoloration, warm |
| Pulses | Diminished/absent | Present |
| Edema | Minimal | Significant |
| Ulcers | Painful, on toes/lateral malleolus | Less painful, medial ankle |
| Position relief | Better dependent (legs down) | Better elevated |
Arterial: keep warm (never hot), avoid leg crossing, stop smoking. Venous: elevate legs, compression stockings, avoid prolonged standing.
Shock
| Type | Cause | Distinguishing finding |
|---|---|---|
| Hypovolemic | Blood/fluid loss | Tachycardia, oliguria, cool clammy skin |
| Cardiogenic | Pump failure (MI, HF) | Crackles, JVD, hypotension |
| Distributive/septic | Infection vasodilation | Warm/flushed early, then cold; fever |
| Anaphylactic | Allergen | Urticaria, stridor, angioedema |
| Neurogenic | Spinal cord injury | Bradycardia with hypotension, warm dry skin |
Early shock = compensated: tachycardia, restlessness/anxiety, tachypnea, falling urine output — before the blood pressure drops. By the time hypotension, confusion, and a weak thready pulse appear, shock is decompensating. The tested action is to recognize the early signs and notify the RN immediately.
Why the Patterns Matter on Exam Day
The NCLEX-PN rarely asks you to name a disease; it asks what to do with the findings in front of you. That is why the left-versus-right and arterial-versus-venous splits are worth memorizing cold. If a question describes crackles, pink frothy sputum, and orthopnea, you should immediately picture fluid in the lungs from left-sided failure and choose to raise the head of bed, give oxygen, and report — not to lay the patient flat.
If it describes brown-stained ankles and edema relieved by elevation, you are looking at venous disease and should choose compression and leg elevation, never the warming-and-dependency measures used for arterial disease.
Patient Teaching and Prevention
LPN/VN cardiovascular items lean heavily on teaching, because prevention and adherence are within scope. Reinforce these points and recognize them as correct answers:
- Heart failure: weigh daily at the same time, report a gain of 2–3 lb in a day or 5 lb in a week, limit sodium, and never skip diuretics or take a double dose to "catch up."
- Post-MI / coronary disease: resume activity gradually, carry sublingual nitroglycerin and replace it every 3–6 months (store in the original dark glass bottle), and stop smoking — the single most powerful modifiable risk factor.
- Atrial fibrillation on warfarin: keep vitamin K intake (leafy greens) consistent rather than eliminated, report bleeding or bruising, and attend INR checks.
- Peripheral arterial disease: inspect the feet daily, wear well-fitting shoes, avoid heating pads (neuropathy plus poor perfusion risks burns), and walk to the point of claudication to build collateral circulation.
Vital-Sign Trends Beat Single Numbers
As with neuro assessment, the cardiovascular exam rewards trend recognition. A narrowing pulse pressure, a creeping heart rate, and a urine output sliding below 30 mL/hr together signal that compensation is failing — even when each individual value still looks acceptable. The LPN/VN who reports the trend to the RN, rather than waiting for a single alarming number, is demonstrating exactly the prioritization the test rewards.
A patient with left-sided heart failure would most likely present with which findings?
Peripheral edema and jugular venous distention
Dyspnea, orthopnea, and crackles in the lungs
Hepatomegaly and ascites
Dependent edema and weight gain only
Before administering the morning digoxin, the LPN/VN counts an apical pulse of 52 and the patient reports seeing yellow-green halos. The nurse should:
Administer the dose and document the findings
Hold the dose and report the findings to the RN/provider
Give half the ordered dose
Administer the dose with extra fluids
Which finding differentiates arterial insufficiency from venous insufficiency?
Arterial: brown skin discoloration; Venous: pale, shiny skin
Arterial: significant edema; Venous: minimal edema
Arterial: diminished pulses; Venous: present pulses
Arterial: pain relieved by elevation; Venous: pain relieved by dependency
Which set of findings represents EARLY (compensated) shock?
Hypotension, anuria, and mottled skin
Tachycardia, restlessness, and decreasing urine output
Confusion, weak thready pulse, and bradycardia
Cyanosis, fixed pupils, and absent reflexes
Sections you finish are checked off in the contents.