Cardiovascular nursing is among the most heavily tested areas on the NCLEX. It requires you to recognize life-threatening changes early, prioritize correctly, and know exactly what to do — in the right order.
Heart Failure: Assessment and Nursing Priorities
Left-sided heart failure (pulmonary symptoms)
- Dyspnea, orthopnea, paroxysmal nocturnal dyspnea
- S3 gallop, crackles (rales) at lung bases
- Frothy pink-tinged sputum (pulmonary edema — emergency)
- Fatigue, decreased exercise tolerance
Right-sided heart failure (systemic venous backup)
- Peripheral edema (pitting, dependent)
- Jugular venous distension (JVD)
- Hepatomegaly, ascites
- Weight gain (>2 lb/day or >5 lb/week = notify provider)
Priority nursing interventions for acute HF
- High Fowler's position (sitting upright) — improves respiratory effort immediately
- Oxygen therapy — target SpO2 >94%
- Administer IV diuretics as ordered (monitor hourly urine output)
- Daily weights at same time, same scale, same clothing
- Strict I&O; fluid restriction as prescribed (typically 1.5–2 L/day)
- Monitor electrolytes — furosemide causes hypokalemia
Myocardial Infarction: Nursing Assessment and Action
Classic MI presentation
Crushing substernal chest pain radiating to left arm, jaw, or back. Diaphoresis, nausea, vomiting, anxiety, feeling of "impending doom." Women and diabetics may present atypically: fatigue, shortness of breath, epigastric pain, no chest pain.
Priority nursing actions in suspected MI (MONA — not first-line order anymore, but remember the components)
- 12-lead ECG immediately — first nursing action when MI is suspected
- Notify provider STAT
- IV access, oxygen if SpO2 <94%, continuous cardiac monitoring
- Aspirin 325 mg PO (chew, do not swallow whole)
- Nitrates for pain (hold if SBP <90 or if patient took PDE5 inhibitor in last 24–48 hours)
Post-MI nursing monitoring
Monitor for complications by time frame: early (0–48h): arrhythmias (most common cause of death in first 24 hours), cardiogenic shock. Days 3–5: pericarditis (friction rub, positional chest pain). Days 5–10: free wall rupture, papillary muscle rupture (sudden mitral regurgitation murmur → cardiogenic shock), VSD.
Arrhythmias: Recognition and Nursing Response
| Rhythm | Key EKG features | Nursing action |
|---|---|---|
| Ventricular fibrillation | No organized rhythm, no pulse | Call code, immediate defibrillation, CPR |
| Ventricular tachycardia (pulseless) | Wide QRS, no identifiable P waves, no pulse | Defibrillation immediately |
| Ventricular tachycardia (with pulse) | Wide QRS, HR >100, P waves absent/retrograde | If stable: amiodarone; if unstable (hypotension, altered LOC): synchronized cardioversion |
| Atrial fibrillation | Irregularly irregular rhythm, no P waves, fibrillatory baseline | Rate control (beta-blocker or Ca²⁺ channel blocker); anticoagulation (CHA₂DS₂-VASc score) |
| Third-degree (complete) heart block | P waves and QRS completely dissociated | Atropine; transcutaneous pacing; prepare for permanent pacemaker |
| Asystole | Flat line — confirm in two leads before acting | CPR + epinephrine; no defibrillation |
Cardiac Medications: What the Nurse Must Monitor
| Medication | Hold if | Monitor for |
|---|---|---|
| Digoxin | Apical HR <60 (assess for 1 full minute); level >2 ng/mL | Toxicity: nausea, visual changes (yellow halos), bradycardia; hypokalemia potentiates toxicity |
| Beta-blockers | HR <60, SBP <90 | Bronchospasm, hypotension, masking hypoglycemia in diabetics |
| ACE inhibitors | Potassium >5.5, rising creatinine | Dry cough, angioedema (stop immediately), hyperkalemia |
| Loop diuretics (furosemide) | Urine output <30 mL/hr; potassium <3.5 | Hypokalemia, dehydration, ototoxicity (with high IV doses) |
| Nitrates | SBP <90; recent PDE5 inhibitor use | Hypotension, reflex tachycardia, headache |
Hypertensive Crisis
Hypertensive urgency: Severely elevated BP (>180/120) without evidence of end-organ damage. Oral antihypertensives, gradual reduction over 24–48 hours.
Hypertensive emergency: BP >180/120 + acute end-organ damage (encephalopathy, MI, acute kidney injury, aortic dissection, eclampsia). IV antihypertensives (nicardipine, labetalol, sodium nitroprusside). Reduce MAP by no more than 25% in first hour — too rapid a drop causes ischemic stroke or MI.
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