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?
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:
Which finding differentiates arterial insufficiency from venous insufficiency?
Which set of findings represents EARLY (compensated) shock?