NCLEX-PN · Physiological Adaptation · 7 min read
Cardiac Emergencies, Dysrhythmias and Vascular Disorders
- Differentiate between left- and right-sided heart failure manifestations, monitor fluid balance, and recognize signs of acute pulmonary edema and digoxin toxicity.
- Collect data on acute coronary syndromes and dysrhythmias, implement safe nitroglycerin protocols, and carry out emergency actions within the LPN/VN scope of practice.
- Distinguish between arterial and venous peripheral vascular disorders, identify complications of hypertensive crises, and reinforce appropriate client teaching.
Heart Failure and Acute Pulmonary Edema
Heart failure occurs when the heart muscle cannot pump blood efficiently to meet the body's needs. Left-sided heart failure causes pulmonary congestion because blood backs up into the lungs. When collecting data, the practical nurse notes crackles, dyspnea, orthopnea, and a cough. In contrast, right-sided heart failure causes systemic venous congestion as blood backs up into the body, leading to jugular venous distention, peripheral edema, and hepatomegaly. B-type natriuretic peptide is a cardiac biomarker that is elevated in the presence of increased ventricular filling pressure during a heart failure exacerbation.
A severe complication of heart failure is acute pulmonary edema, where fluid rapidly fills the alveoli. The classic sign is pink, frothy sputum, which requires immediate reporting to the registered nurse. The practical nurse places a client experiencing acute pulmonary edema in the high-Fowler position. This posture uses gravity to decrease venous return to the heart and facilitates breathing by allowing maximum chest expansion.
To monitor fluid retention, the practical nurse weighs the client with heart failure daily in the morning after voiding using the same scale. A weight gain of two to three pounds in a day or five pounds in a week indicates fluid retention and must be reported promptly to the RN. The practical nurse also reinforces dietary education limiting sodium intake to reduce fluid retention.
Medication management often includes digoxin. The practical nurse counts the apical pulse for one full minute before administering digoxin, withholds the dose if an adult's pulse is below 60 beats per minute or below the prescribed parameter, and reports the finding to the RN. Hypokalemia increases the risk of digoxin toxicity in clients receiving loop or thiazide diuretics. Manifestations of digoxin toxicity include anorexia, nausea, vomiting, fatigue, and visual changes such as yellow-green discoloration or halos.
| Feature | Left-Sided Heart Failure | Right-Sided Heart Failure |
|---|---|---|
| Primary Pathophysiology | Pulmonary congestion due to backup into the lungs | Systemic venous congestion due to backup into the body |
| Key Clinical Manifestations | Crackles, dyspnea, orthopnea, and cough | Jugular venous distention, peripheral edema, and hepatomegaly |
Common mistakes
- Elevating the legs of a client with severe peripheral artery disease instead of placing them in a dependent position to relieve ischemic rest pain.
- Massaging a tender, swollen, erythematous calf, which risks dislodging a deep vein thrombosis into circulation and causing a pulmonary embolism.
- Failing to check blood pressure before administering sublingual nitroglycerin, or administering it to a client who recently took a phosphodiesterase-5 inhibitor.
- Assuming all clients experiencing a myocardial infarction will report classic crushing chest pain, thereby missing atypical presentations like dyspnea, fatigue, or epigastric pain in female, older adult, or diabetic clients.
Key points
- Left-sided heart failure causes pulmonary congestion (crackles, dyspnea, orthopnea, cough), whereas right-sided heart failure produces systemic congestion (jugular venous distention, peripheral edema, hepatomegaly); pink, frothy sputum signals acute pulmonary edema requiring high-Fowler positioning and immediate RN notification.
- Monitor daily morning weights on the same scale after voiding, report gains of 2 to 3 pounds in a day or 5 pounds in a week, reinforce sodium restriction, and check the apical pulse for one full minute before giving digoxin, holding for a rate below 60 beats per minute.
- Check blood pressure before giving nitroglycerin, withhold it after recent phosphodiesterase-5 inhibitor use (24 hours for sildenafil or vardenafil; 48 hours for tadalafil), reinforce calling emergency medical services if pain persists 5 minutes after the first dose, and promptly report oxygen saturation below 90% to the RN and administer oxygen as prescribed or under an approved protocol.
- For abnormal telemetry, immediately check the client's responsiveness and pulse; if ventricular fibrillation or pulseless ventricular tachycardia is suspected, call for emergency help and begin chest compressions without waiting to check blood pressure, and if the client has a pulse, check blood pressure and alert the RN.
- Hypertensive emergency involves acute target-organ damage (brain, kidneys, heart, retina, aorta); maintain bed rest, monitor blood pressure and neuro checks frequently, and avoid lowering blood pressure too rapidly to prevent organ hypoperfusion.
- Differentiate peripheral artery disease (claudication, cool skin, pallor on elevation, dependent rubor, deep punched-out toe ulcers) from chronic venous insufficiency (edema, brown hyperpigmentation, shallow medial malleolus ulcers); elevate venous limbs but keep arterial limbs dependent for rest pain.
- Never massage an extremity with suspected deep vein thrombosis due to pulmonary embolism risk, apply graduated compression stockings before rising in the morning, and reinforce avoiding cold and tobacco for clients with Raynaud phenomenon.
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