N401= Cardiac part 3

Week 3- Heart failure, cardiomyopathies and Emergency Nursing Triage

Heart Failure (HF)

clinical syndrome in which the heart is unable to pump enough blood to meet thebody's metabolic. It does not mean that the heart has stopped working; rather, it is functioning less efficiently. Heart cannot pump enough blood to meet bodies demands.​

-Classification​= By Left Ventricular Ejection Fraction (LVEF)​. Heart failure with reduced ejection fraction(HFrEF): LVEF ≤40%. Heart failure with mildly reduced ejection fraction(HFmrEF): LVEF 41–49%. Heart failure with preserved ejection fraction(HFpEF): LVEF ≥50%​

Ejection fraction (EF)

is the percentage of blood aheart ventricle pumps out with each contraction. It is most commonly measured for the left ventricle (LVEF),which pumps blood to the body.

LVEF

≥50–55%​	Generally normal​
41–49%​	Mildly reduced / borderline​
≤40%​	Reduced​
<30–35%​	Severely reduced in many clinical contexts​

Heart failure develops due to?

Reduced cardiac output ​

Activation of compensatory mechanisms: ​

-Sympathetic nervous system= epinephrine kicks in, fight or flight​

-Renin–angiotensin–aldosterone system(RAAS)= blocks angiotensin​

-Antidiuretic hormone (ADH)= fluid overload, heart will fail​

These initially maintain circulation but eventually lead to: ​Fluid retention, Vasoconstriction, Cardiac remodeling, Progressive decline in cardiac function​

Causes of Heart Failure​

Coronary artery disease and previous myocardialinfarction ​

Hypertension ​

Cardiomyopathy ​

Valvular heart disease ​

Arrhythmias (e.g., atrial fibrillation) ​

Congenital heart disease ​

Diabetes mellitus/Metabolic Syndrome​

Chronic kidney disease ​

Alcohol or drug toxicity ​

Viral myocarditis ​

Sleep apnea= main cause of right sided heart failure​

Smoking​

High sodium diet​

Heart Failure Laboratory Tests

​

BNP or NT-proBNP (elevated in heart failure) ​

BNP equivalent to heart failure as Tropnin is to MI. BMP should be under 100.. BMPtells us how well the heart is pumping and how much fluid there is. Tells us if patientis compliant with lifestyle changes.​

Complete blood count ​

Electrolytes ​

Renal function tests ​

Liver function tests ​

Thyroid function tests ​

Cardiac troponins (when myocardial injury is suspected)​

Heart Failure Imaging

ECG: Arrhythmias, ischemia, ventricular hypertrophy ​

Chest X-ray: Cardiomegaly, pulmonary edema, pleural effusions ​

Echocardiography (gold standard): ​

Ejection fraction ​

Valve function ​

Chamber size ​

Wall motion abnormalities ​

Cardiac MRI or coronary angiography when indicated ​

Treatment of Heart Failure

Lifestyle Measures​= Sodium restriction, Fluid restriction (selected patients), Regular physical activity as tolerated ​

-Weight monitoring. Smoking cessation, Limit alcohol intake. Vaccinations (influenza and pneumococcal)​

Diuretics​

Loop Diuretics- potassium wasting​. Furosemide (Lasix), Bumetanide (Bumex). Torsemide ​

Mechanism​= Act on the loop of Henle to cause significant sodium and water excretion.​

Why are they given?​ They decrease- Pulmonary congestion, Peripheral edema, Dyspnea, Fluid overload​

Nursing considerations= take due to fluid overload, more urine output, lookat hypertension, dehydration, electrolyte imbalances.​

Monitor:​ Daily weight, Intake and output, Blood pressure, Lung sounds. Edema ​

-Potassium, Sodium, Magnesium. BUN/creatinine ​

Major adverse effects​= Hypokalemia, Hypotension, Dehydration, Hyponatremia, Renal dysfunction, Ototoxicity with high doses/rapid IV administration ​​

Furosemide → think "fluid off + potassium off."​

What is the goal of Heart Failure​ treatment?

The main goals of heart failure pharmacology are to improve cardiac function, reduce fluid overload, decrease symptoms, prevent hospitalization, andimprove survival.​ The 4 Foundational Medications for HFrEF​

For heart failure with reduced ejection fraction(HFrEF), four medication classes form the foundation of treatment:​

NCLEX tip: These medications generally improve outcomes in HFrEF; loop diuretics primarily provide symptom relief from fluid overload rather than being one of the four foundational mortality-reducing therapies.​

Key points to know for ARNI​

Examples- Sacubitril/valsartan​

Main Action= Reduces vasoconstriction and sodium/water retention​

Key Nursing Considerations= Monitor BP, potassium, renal function; watch for angioedema​

Key points to know for Beta Blockers

Examples= Carvedilol, metoprolol succinate, bisoprolol​

Main Action= Decreases HR and sympathetic stimulation​

Key Nursing Considerations= Monitor HR/BP; don't abruptly discontinue​

Key points to know Mineralocorticoid receptor antagonists​

Examples= Spironolactone, eplerenone​

Main actions= Promotes sodium/water excretion while retaining potassium​

Key Nursing Consideration= Monitor K⁺ and renal function​

Key point to know for SGLT2 inhibitors

Examples= Dapagliflozin, empagliflozin​

Mian Action= Promotes glucose/sodium excretion and beneficial cardiac/renal effects​

Key Nursing Considerations= Monitor volume status, renal function, genital infections​

ACE Inhibitors​

end in -pril​= Lisinopril, Enalapril, Captopril ​

Mechanism​= Inhibit formation of angiotensin II → vasodilation →decreased afterload and reduced aldosterone-mediated fluid retention.​

Benefits​= Decreases workload on the heart, Reduces remodeling, Improves symptoms and outcomes in appropriate patients​

Adverse effects​= Hypotension, Hyperkalemia, Renal dysfunction, Persistent dry cough, Angioedema, Nursing considerations​

Monitor:​ BP, Potassium, BUN/creatinine. Hold/notify provider according to institutional parameters if significant hypotension, renal deterioration, or hyperkalemia develops.​

Memory trick​= A Cough + Elevated potassium

ARBs/ARNIs​

end in -sartan​= Losartan, Valsartan, Candesartan ​

Used when an ACE inhibitor isn't tolerated, such asbecause of cough.​

Major adverse effects​= Hypotension, Hyperkalemia, Renal dysfunction, Rarely angioedema ​

Important: ARBs generally do not cause the persistent cough associated with ACE inhibitors.​

Sacubitril/valsartan​

This combines:​ Sacubitril → neprilysin inhibitor, Valsartan → ARB. It is an important therapy for many patients with HFrEF.​

Nursing considerations​- Monitor:​ BP, Potassium, Renal function, Signs of angioedema ​

VERY IMPORTANT NCLEX POINT​= Do NOT administer sacubitril/valsartan with an ACE inhibitor.​There must generally be a 36-hour washout period afterstopping an ACE inhibitor before starting sacubitril/valsartan because of increased risk of angioedema.​

Beta-Blockers​

end in -olol​= Carvedilol, Metoprolol succinate = cardioseletive​, Bisoprolol ​

Mechanism​= Reduce sympathetic stimulation → decrease HR and myocardial oxygen demand and help prevent adverse cardiac remodeling.​

Nursing considerations= be cautious with certain beta blockers, can be cardio selective and non-cardioselective. Usally give cardioselective. Only work on Alpha 1. Non-cardio work on alpha 2 too and work on lungs. ​

Monitor: HR, BP and Signs of worsening HF​

Important concept​= Beta-blockers can initially cause: Fatigue, Bradycardia, Hypotension, Temporary worsening of HF symptoms ​

They are generally started at low doses and gradually increased in stable patients.​

NCLEX Tip​= Do not abruptly stop beta-blockers.​ Abrupt withdrawal can cause significant cardiovascular complications.​

Mineralocorticoid Receptor Antagonists​

Examples​= Spironolactone= spares potassium.​ Eplerenone ​

Mechanism= Block aldosterone →decrease sodium/water retention while reducing potassium loss.​

Major concern​= 🚨 HYPERKALEMIA​. Monitor:​ Potassium, Renal function, BP​

Spironolactone-specific adverse effect​

Gynecomastia and other endocrine effects can occur. Can lead to Manboobs​

Eplerenone is more selective and has fewer endocrine adverse effects.​

Memory trick​= Spironolactone = "SPARE potassium."​

SGLT2 Inhibitors​

end in -flozin​= Dapagliflozin, Empagliflozin ​

Originally developed as diabetes medications, but they also have important benefits in heart failure, including in many patients without diabetes.​

Effects​= Promote urinary glucose and sodium excretion, Reduce volume burden Provide cardiovascular and renal benefits​

Nursing considerations= diabetic med but also can give to patients without diabetes to help manage fluid. ​

Monitor: Renal function, Volume status, Blood pressure, Signs of genital/urinary infections ​

Potential adverse effects​= Genital mycotic infections, Volume depletion, Hypotension. Rarely, euglycemic diabetic ketoacidosis​

Digoxin​

Mechanism​=Increases myocardial contractility (positive inotropic effect), Decreases AV-node conduction. Can decrease heart rate ​

Important point​= Digoxin can improve symptoms and reduce hospitalizations, but it does not provide the same mortality benefit as the foundational HFrEF therapies.

​Toxicity​= 🚨 Digoxin toxicity​. Signs can include:​ Nausea/vomiting, Anorexia, Fatigue, Confusion, Bradycardia, Dysrhythmias. Visual disturbances, such as yellow/green vision or blurred vision ​

Nursing considerations​= Check: always check apical pulse for 1 min before giving, Apical pulse, Digoxin level when indicated, Potassium, Renal function ​

Critical NCLEX connection​= Hypokalemia increases the risk of digoxin toxicity.​

Therefore, a patient taking furosemide + digoxin requires careful potassium monitoring.​

The general therapeutic range for digoxin is 0.5 to 2.0 ng/mL ​

What is the therapeutic range of Digoxin?

is 0.5 to 2.0 ng/mL

Vasodilators​

Hydralazine + Isosorbide Dinitrate​

This combination can be used in selected patients with HFrEF, particularly when other therapies cannot be used or in specific populations where evidence supports it.​

Effects​= Hydralazine: arterial vasodilation → decreases afterload. Isosorbide dinitrate: venous dilation → decreases preload ​

Adverse effects​= Hypotension, Headache, Dizziness, Reflex tachycardia​

⭐ High-Yield Nursing Priorities​ for patients with Heart Failure

When caring for a patient taking heart failure medications, think:​ Daily weight​

The best routine indicator of fluid status.​ Report significant rapid weight gain according to the patient's prescribed action plan.​

-Blood pressure​, Many HF medications lower BP.​ Potassium​

Medication​	Potassium Effect​
Furosemide​	↓ K⁺​
Spironolactone​	↑ K⁺​
ACE inhibitors​	↑ K⁺​
ARBs​	↑ K⁺​
ARNI​	↑ K⁺​
Digoxin​	Toxicity risk ↑ when K⁺ is low​

Treatment- if medications and lifestyle modifications do not work.​

Device Therapy​= Implantable cardioverter-defibrillator(ICD)- with ejection fraction less than 40%, Cardiac resynchronization therapy (CRT)​

Advanced Therapies​= Left ventricular assist device (LVAD)-help left ventricle pump more effectively, Heart transplantation​

Prognosis of Heart Failure

depends on:​ Severity of heart failure, Ejection fraction, Underlying cause, Response to treatment ​

Presence of other medical conditions (e.g.,diabetes, kidney disease) ​

Early diagnosis, guideline-directed medical therapy, and lifestyle modifications can significantly improve quality of life, reduce hospitalizations, and increase survival.​

❤ Left-Sided Heart Failure​

occurs when the left ventricle cannot effectively pump blood into systemic circulation.​ Blood backs up into the pulmonary circulation →pulmonary congestion.​

Major Causes; Hypertension, Coronary artery disease,Myocardial infarction, Cardiomyopathy, and Aortic or mitral valve disease​

Left ventricle cannot pump and backs up to lungs and possible systemic. Common to start left sided heart failure and lead to right sided heart failure.​

Key Symptoms & Signs​= Think: LUNGS​- Dyspnea, Orthopnea, Paroxysmal nocturnal dyspnea, Crackles, Cough, Pulmonary edema. Decreased oxygen saturation ​Fatigue, Exercise intolerance ​

Pink, frothy sputum with severe acute pulmonary edema** Pulmonary edema symptoms with left sided heart failure need to be treated​. S3 heart sound may be present​

❤ Left-Sided Heart Failure Pathophysiology and Complications​

Left ventricle fails → blood backs up into left atrium →pulmonary veins → lungs →pulmonary congestion. This causes fluid to move into the pulmonary interstitial/alveolar spaces, making gas exchange more difficult.​

🚨 Priority Complication​= Acute pulmonary edema​

Signs may include:​ Severe dyspnea, Hypoxemia, Crackles, Anxiety/restlessness, Tachypnea, Pink, frothy sputum, This is an emergency.​

Pulmonary edema

is a condition in which excess fluid accumulates in the interstitial tissue and alveoli of the lungs, interfering with oxygen and carbon dioxide exchange.​

The most common cardiac cause is acute left-sided heart failure, but _ can also occur from non-cardiac causes.​

Normally, pulmonary capillaries allow oxygen and carbon dioxide to exchange across thin alveolar walls.​ With pulmonary edema:​

Left ventricular dysfunction​
↓​
Blood backs up into the left atrium​
↓​
↑ Pulmonary venous pressure​
↓​
↑ Pulmonary capillary hydrostatic pressure​
↓​
Fluid moves into lung tissue and alveoli​
↓​
Impaired gas exchange​
↓​
Hypoxemia + respiratory distress​

Easy way to remember:​ Left-sided heart failure → fluid backs up into the LUNGS → pulmonary edema​

Manifestations of Pulmonary Edema​

Early Findings​= Dyspnea, Tachypnea, Anxiety/restlessness, Tachycardia, Decreased oxygen saturation, Cough, Crackles​

Severe Manifestations= 🚨 Medical emergency​= Severe respiratory distress, Significant hypoxemia, Diffuse crackles. Orthopnea, Cyanosis ​

-Diaphoresis, Extreme anxiety or feeling of impending doom, Pink, frothy sputum ​Possible altered mental status, Possible respiratory failure ​

Classic Finding​= Pink, frothy sputum = severe ​

Assessment​ Left Heart Failure

The nurse should rapidly assess:​ Airway​, Is the airway patent? ​Breathing​, Respiratory rate, Work of breathing, Oxygen saturation, Lung sounds, Ability to speak, Signs of respiratory fatigue​

Circulation​, Heart rate, Blood pressure, Peripheral perfusion, Cardiac rhythm ​

Also assess for signs of underlying heart failure:​ JVD, Peripheral edema, Rapid weight gain, S3 heart sound ​

🚨 Nursing Priorities​ of Left Heart Failure

1. Position the patient upright​- Place the patient in:​ High-Fowler's position​. This can improve lung expansion and decrease venous return to the heart.​

2. Oxygen​= Administer supplemental oxygen as prescribed and monitor response.​If hypoxemia or respiratory distress remains severe, the patient may require:​ Noninvasive positive-pressure ventilation such as CPAP/BiPAP, Advanced airway management/mechanical ventilation if necessary​

3. Reduce fluid overload​= For cardiogenic pulmonary edema, medications may include:​ Loop diuretics​, Furosemide, Bumetanide ​

-Monitor:​ Urine output, BP, Potassium, Sodium, Renal function ​

4. Reduce cardiac workload whenappropriate​= Depending on blood pressure and clinical status, medications may be used to reduce preload and/or afterload.​

-For example:​ Nitrates may be used in appropriate patients, particularly when pulmonary edema is associated with significant hypertension.​

💙 Right-Sided Heart Failure​

occurs when the right ventricle cannot effectively pump blood into the pulmonary circulation.​ Blood backs up into the systemic venous circulation →peripheral/systemic congestion.​

Major Cause​= The most common cause of _-sided heart failure is left-sided heart failure.​

Other causes include:​ Pulmonary hypertension, Chronic lung disease, Right ventricular infarction,Tricuspid or pulmonic valve disease​

Key Symptoms & Signs​ of Right sided Heart Failure

Think: BODY​

-Peripheral edema, Weight gain, Jugular venous distention (JVD), Hepatomegaly ​

-Ascites, Abdominal discomfort/fullness, Anorexia, Dependent edema, Nocturia ​

-Increased central venous pressure ​

Pathophysiology​= Right ventricle fails → blood backs up into right atrium → systemic veins →organs/tissues → systemic venous congestion​

🔥 Side-by-Side Comparison​- Right sided heart failure vs Left sided heart failure

Finding​	Left-Sided HF​	Right-Sided HF​
Main problem​	Pumping blood to body​	Pumping blood to lungs​
Blood backs up into​	Lungs​	Systemic circulation​
Classic congestion​	Pulmonary​	Peripheral/systemic​
Dyspnea​	⭐⭐⭐​	Can occur, especially if left HF is also present​
Orthopnea​	⭐⭐⭐​	Less characteristic​
Crackles​	⭐⭐⭐​	Usually not the primary finding​
Pulmonary edema​	⭐⭐⭐​	Not primary​
Peripheral edema​	Can occur​	⭐⭐⭐​
JVD​	May occur​	⭐⭐⭐​
Hepatomegaly​	Less characteristic​	⭐⭐⭐​
Ascites​	Less characteristic​	⭐⭐⭐​
Weight gain​	Possible​	⭐⭐⭐​
Pink frothy sputum​	Severe pulmonary edema​	Not typical​
S3​	Commonly associated​	May occur​

🧠 Pulmonary Edema vs. Peripheral Edema​

Pulmonary Edema​	Peripheral Edema​
Fluid in lungs​	Fluid in tissues​
Difficulty breathing​	Swollen legs/feet​
Crackles​	Pitting edema​
Hypoxemia​	Weight gain​
Orthopnea​	Tight shoes/rings​
Pink frothy sputum in severe cases​	JVD may occur​
Life-threatening respiratory emergency​	Usually less immediately life-threatening​

⭐ Important Connection​= Left- and right-sided heart failure frequently occur together.​

A common progression is:​ Left ventricular dysfunction​ →​
Blood backs up into lungs​↓​
↑ Pulmonary pressure​
↓​Increased workload on right ventricle​
↓​Right ventricular dysfunction​
↓​Systemic venous congestion​
↓​JVD + peripheral edema + hepatomegaly + ascites​

NCLEX Priority​= If a patient with left-sided HF suddenly develops severe respiratory distress, hypoxemia, diffuse crackles, and pink frothy sputum, think:​

🚨 Acute pulmonary edema → airway/breathing isthe immediate priority.​

If a patient with right-sided HF has rapid weight gain, increasing edema, JVD, and abdominal distention, think:​ Systemic fluid overload.​

Key Points​ of Heart Failure

Heart failure is a syndrome of impaired cardiacfunction, not cardiac arrest. ​

The major types are HFrEF, HFmrEF, and HFpEF. ​

Echocardiography is the cornerstone of diagnosis. ​

HFrEF treatment includes four foundational drug classes: ARNI/ACE inhibitor/ARB, beta-blocker, mineralocorticoid receptor antagonist, andSGLT2 inhibitor. ​

Early treatment and management of underlying causes are essential for improving outcomes.​

Heart Failure Disease Prevention​

prevention focuses on controlling risk factors, preventing cardiovascular disease, recognizing early symptoms, and preventing exacerbations.

For nursing students, it helps to think about prevention in three stages:​ Prevent HF → Detect HF early → Prevent worsening HF​

🫀Control Major Risk Factors to prevent Heart Failure​

Many cases of heart failure can be prevented or delayed by managing conditions that damage the heart.​

Control hypertension​, High blood pressure increases the workload of the heart and can eventually cause ventricular remodeling and heart failure.​ Monitor BP regularly, Take prescribed antihypertensives, Follow a heart-healthy diet, Maintain a healthy weight, Exercise regularly​

Prevent and manage coronary artery disease​= Coronary artery disease and myocardial infarction are major causes of heart failure.​ Encourage:​ Smoking cessation, Regular physical activity, Healthy diet, Cholesterol management, Diabetes management. Appropriate cardiovascular medications​

Manage diabetes​= Poorly controlled diabetes increases cardiovascular risk.​ Monitor glucose as recommended, Follow prescribed medications. Maintain a healthy weight, Exercise regularly, Attend routine medical visits​

🥗 Follow a Heart-Healthy Diet to prevent Heart Failure​

Encourage a diet emphasizing:​ Fruits and vegetables, Whole grains, Lean proteins, Fish, Legumes, Nuts and seeds, Healthy fats​

Limit:​ Excess sodium, Highly processed foods,Saturated fats, Trans fats, Added sugars. Sodium​= Excess sodium promotes water retention, which can worsen congestion in people with heart failure.​ For patients who already have HF, sodium recommendations should follow their individualized treatment plan.​

🏃 MaintainRegular Physical Activity to prevent Heart Failure​

Regular physical activity can:​ Improve cardiovascular fitness, Help control BP, Improve weight management ​

-Improve glucose control, Reduce cardiovascular risk ​

-Patients with established HF should follow an exercise plan appropriate for their condition and provider recommendations.​

Disease Prevention for Heart Failure​

🚭 Stop Smoking​- Smoking contributes to:​ Coronary artery disease, Hypertension Vascular disease, Reduced oxygen delivery. Smoking cessation is one of the most important cardiovascular prevention strategies.​

⚖ Maintain a Healthy Weight​= Obesity increases the risk of:​ Hypertension, Diabetes, Coronary artery disease, Sleep apnea, Heart failure. Weight management should focus on sustainable nutrition, physical activity, and behavioral changes.​

🍺 Limit Alcohol​= Excessive alcohol consumption can contribute to:​ Hypertension, Cardiomyopathy, Arrhythmias, Heart failure. Patients should discuss alcohol intake with their healthcare provider, particularly if they already have cardiac disease.​

💊 Take Medications as Prescribed​= For patients with conditions that increase HF risk, appropriate treatment can help prevent progression.​ Examples include medications used to manage:​ Hypertension, Diabetes, Hyperlipidemia. Coronary artery disease. For patients who already haveHFrEF, guideline-directed medications can reduce hospitalization and cardiovascular events.​

💧 Prevent Fluid Overload in Established HF​- Depending on the patient's condition and prescribed plan:​ Follow sodium restrictions. ​Follow individualized fluid recommendations. ​Take diuretics as prescribed. ​Monitor daily weight. ​Monitor edema. ​Keep follow-up appointments. ​Do not automatically recommend fluid restriction to every HF patient. Fluid restriction is individualized and is particularly considered in selected patients with significant congestion or hyponatremia.​

💊 Avoid Medications ThatCan Worsen HF​= Patients should check with their healthcare provider before taking new medications, including OTC drugs.​Important example: NSAIDs​, NSAIDs such as ibuprofen and naproxen can contribute to: Sodium/water retention, Increased BP, Kidney dysfunction. These effects can worsen HF insusceptible patients.​

🩺 Recognize Heart Failure Early​

Symptoms to watch for:​ Increasing shortness of breath, New or worsening orthopnea, Increasing fatigue. Peripheral edema, Persistent cough, Rapid weight gain ​Abdominal swelling. Decreased ability to perform usual activities​

🚨 Important nursing teaching​- For a patient with established HF:​ Daily weights are one of the most useful ways to detect fluid retention early.​

Teach the patient to:​ Weigh themselves every morning. ​Use the same scale. ​Weigh after urinating. ​Weigh before eating. ​Wear similar clothing. ​Record the weight. ​

Patients should follow their provider's specific instructions for when weight gain requires a call.​

Why do we need to prevent Infections in Heart failure paitients?

Infections can trigger acute HF exacerbations.​ Encourage appropriate:​ Influenza vaccination, Pneumococcal vaccination, COVID-19 vaccination, Hand hygiene. Prompt evaluation of significant infections ​

-Vaccination recommendations should be individualized based on age and medical conditions.​

Cardiomyopathy is

a group of diseases that primarily affect the heart muscle (myocardium). The heart muscle may become enlarged, thickened, stiff, or replaced by scar tissue, reducing its ability to pump blood effectively. Some forms also predispose patients to abnormal heart rhythms and sudden cardiac death.​

Causes of Cardiomyopathy​

may be inherited or acquired. Causes include genetic mutations, myocarditis and other infections, long-term heavy alcohol exposure, certain cardiotoxic drugs such as some chemotherapy agents, pregnancy-associated cardiomyopathy, metabolic or endocrine disorders, and infiltrative diseases such as amyloidosis.Sometimes no specific cause is identified.

Major types​ of Cardiomyopathy​

Dilated cardiomyopathy (DCM)​	Ventricles enlarge and contract poorly. Ventricles enlarged, does not contract, big, enlarged, floppy ventricles, reduced ejection fraction and lead to heart failure. Most common. Systolic dysfunction.​	Reduced ejection fraction, heart failure, arrhythmias​
Hypertrophic cardiomyopathy (HCM)​	Abnormal thickening of the myocardium, often the interventricular septum, thickening of heart, diastolic dysfunction​	Diastolic dysfunction/ arrhythmias/syncope​
Restrictive cardiomyopathy (RCM)​	Ventricles become stiff with impaired filling. Problem with filling​	Diastolic dysfunction, congestion, relatively preserved EF early​
Arrhythmogenic cardiomyopathy​	Myocardium is progressively replaced by fibrous/fatty tissue​	Ventricular arrhythmias and increased sudden-death risk​

Dilated Cardiomyopathy​

Think: “Dilated = stretched and weak.”​ Ventricular muscle becomes weakened. ​

The ventricle dilates/enlarges to accommodate blood. ​Contractility decreases. ​

Stroke volume and cardiac output decrease. ​The body activates the sympathetic nervous system and RAAS to maintain perfusion. ​

Increased fluid retention and vasoconstriction increase cardiac workload. ​

Progressive remodeling can lead to heart failure and dysrhythmias.​

Hypertrophic Cardiomyopathy​

is a usually an inherited disorder of the cardiac muscle characterized by abnormal thickening of the myocardium. The thickened muscle becomes stiff and less compliant, making it difficult for the ventricles to fill during diastole.​

A key nursing concept is:​ HCM = thick heart → poor filling → decreased cardiac output.​

Pathophysiology​= The ventricular myocardium becomes abnormally thickened. ​The thick ventricle becomes stiff and has decreased compliance. ​The left ventricle has difficulty filling during diastole. ​Increased filling pressures can develop. ​Cardiac output can decrease, particularly with decreased preload. ​

-Patients are at increased risk for ventricular dysrhythmias and sudden cardiac death.​

Restrictive Cardiomyopathy​

a disorder in which the ventricular walls become stiff and rigid, making it difficult for the ventricles to relax and fill with blood during diastole.​

🫀 Key Concept​= Restrictive = rigid → poor ventricular filling → decreased cardiac output​. Unlike dilated cardiomyopathy, the ventricles are generally not significantly enlarged. Unlike hypertrophic cardiomyopathy, the primary problem is stiffness rather than marked muscle thickening.​

Pathophysiology​= The myocardium becomes stiff and less compliant. ​The ventricles cannot relax normally during diastole. ​Ventricular filling decreases. ​

-Pressure increases inside the ventricles and atria. ​Blood backs up into the pulmonary and systemic circulation. ​The patient develops symptoms of heart failure, particularly congestion. ​Systolic function may remain relatively preserved initially but can decline as the disease progresses.​

Arrhythmogenic cardiomyopathy​

is a usually inherited heart muscle disorder in which cardiac muscle cells are progressively replaced by fibrous and fatty tissue. This creates an abnormal electrical environment and increases the risk of ventricular dysrhythmias and sudden cardiac death.​

It was historically called arrhythmogenic right ventricular cardiomyopathy(ARVC) because the right ventricle was thought to be primarily affected.However, the disease can involve the left ventricle or both ventricles, so arrhythmogenic cardiomyopathy is now the broader term.​

🫀 Key Concept​= Arrhythmogenic = abnormal myocardium → abnormal electrical conduction→ ventricular dysrhythmias.​

Pathophysiology​= Genetic abnormalities affect proteins that help cardiac muscle cells adhere to one another. The damaged myocardium is replaced by fibrous and fatty tissue. ​This replacement disrupts normal electrical conduction. ​

The patient becomes susceptible to ventricular tachycardia and other dysrhythmias. ​Progressive disease can cause ventricular dysfunction and heart failure.​

🫀 Key Diagnostic Tests​ Cardiomyopathy

Echocardiogram (Echo)​	Heart structure, wall thickness, chamber size, valves, EF​	Dilated chambers, thickened walls, impaired filling or contraction​
ECG/EKG​	Electrical activity and rhythm​	Dysrhythmias, conduction abnormalities, ST-T changes, hypertrophy​
Chest X-ray​	Heart size and pulmonary status​	Cardiomegaly, pulmonary congestion/edema​
Cardiac MRI​	Detailed myocardial structure and tissue characteristics​	Fibrosis, scar, infiltration, hypertrophy, ventricular dysfunction​
Blood tests​	Cardiac stress and possible causes​	↑ BNP/NT-proBNP, electrolyte abnormalities, thyroid abnormalities, etc.​
Holter monitor​	Continuous rhythm monitoring​	PVCs, atrial fibrillation, VT, other intermittent dysrhythmias​
Exercise stress testing​	Cardiac response to activity​	Exercise-induced arrhythmias, ischemia, reduced exercise capacity​
Cardiac catheterization​	Coronary arteries and intracardiac pressures​	CAD, abnormal pressures, hemodynamic abnormalities​
Genetic testing​	Inherited cardiomyopathies​	Disease-associated genetic variants​

🧠 Treatment by Type Cardiomyopathies​

Cardiomyopathy​	Treatment Focus​
Dilated​	HFrEF medications, diuretics for congestion, ICD/CRT when indicated​
Hypertrophic​	Beta blockers, symptom management, prevent sudden cardiac death, septal reduction for selected obstructive cases​
Restrictive​	Treat underlying cause, careful fluid management, manage dysrhythmias​
Arrhythmogenic​	Prevent ventricular dysrhythmias, ICD when indicated, avoid high-intensity exercise​

Prioritization For Cardiomyopathies

• ⭐ High-Yield NursingPriorities​

• Think “P-R-E-V-E-N-T”:​

• P – Prevent fluid overload​
  R – Recognize dysrhythmias​
  E – Evaluate cardiac output​
  V – Vital signs, daily weights, I&O​
  E – Educate about medications/lifestyle​
  N – Notice worsening heart-failure symptoms​
  T – Treat the underlying cause​

What to 🚨 Report immediately​

A patient with cardiomyopathy who develops:​

Severe or sudden dyspnea ​

Chest pain ​

New syncope ​

Sustained palpitations ​

Severe hypotension ​

New confusion ​

Pink, frothy sputum ​

Rapidly worsening edema or weight gain ​

may be experiencing acute decompensated heart failure or a dangerous dysrhythmia and requires prompt evaluation.​

What Is Triage?​

is the process of rapidly assessing patients and prioritizing care based on the severity of injuries and the likelihood that treatment will improve outcomes.​

In everyday emergencies, the sickest patients are generally treated first.During a mass casualty incident, however, priorities change because resources may be limited.​

Have to be able to rapidly assess patients and severity of injuries, the sickest patients attended first.​

Mass Casualty Incident (MCI)​

occurs when the number or severity of patients exceeds the available resources of the healthcare system.​

Examples include:​ Major transportation accidents, Building collapses, Fires or explosions, Natural disasters, Large-scale public emergencies ​

The primary goal changes from “the most critically ill first” to “the greatest good for the greatest number.”​

Resources are limited, Number or severity exceeds available resources,Change from most critically ill to greatest good for the greatest number.​

SALT Triage​

stands for Sort, Assess,Lifesaving Interventions,Treatment/Transport. It is a mass-casualty triage method used when there are more patients than available resources.​

Limited resources, limited time.Sort patients based on ability to respond- call out and able to walk then green.​

S in SALT Triage stands for?

Sort​= Quickly sort patients based on their ability to move and respond.​

Call out:​ “Everyone who can walk, move to this area.”​

Walking patients → Green(Minimal) ​

Those who cannot walk are assessed further. ​

Patients who are still or appear critically ill receive rapid assessment.​

A in SALT Triage stands for?

Assess​- Rapidly assess patients for:​ Ability to follow commands, Breathing, Major bleeding, Overall severity, Signs of life ​

The goal is rapid identification, nota complete head-to-toe assessment.​

Who cannot walk and rapidly identify, breathing, and hemorrhage​

L in SALT Triage stands for?

Lifesaving Interventions​

Perform quick interventions that can immediately save a life, such as:​ Control major hemorrhage, Open airway, Provide appropriate ventilation support, Give an antidote when indicated, Position the patient appropriately ​

These interventions should be rapid and limited so one patient doesn't consume resources needed by many others.​

T in SALT Triage stands for?

Treatment/Transport​

Assign a triage category and prioritize treatment/transport. Can change on level of treatment needed.​

Triage Categories​

Category​	Color​	Meaning​	Priority​
Immediate​	🔴 Red​	Life-threatening injury that requires rapid treatment​	Highest​
Delayed​	🟡 Yellow​	Serious injury but treatment can safely wait​	Second​
Minimal​	🟢 Green​	Minor injuries; patient can walk or has relatively minor needs​	Lower​
Expectant/Deceased​	⚫ Black​	Unlikely to survive given available resources, or deceased​	Lowest​

🔴 Immediate

Red​, Patients have life-threatening but potentially treatable conditions.​

Examples:​ Severe bleeding, Airway compromise, Severe respiratory distress, Shock, Certain chest injuries, These patients require rapid intervention.Life threatening but can be treated.​

🟡 Delayed

Yellow​, Patients have significant injuries but can safely wait for treatment without an immediate threat to life.​

Patient has significant wounds but can wait for treatment without threat to life.​

Examples:​ Stable fractures, Moderate burns, Significant but controlled injuries​

🟢 Minimal

Green​, These patients have minor injuries and are sometimes called the“walking wounded.”​

Examples:​ Minor cuts, Small abrasions, Minor sprains, Patients who can walk and follow instructions ​

An important action is to direct walking patients to a designated safe area so healthcare personnel can focus on more seriously injured patients.​

⚫ Expectant/Deceased

Black, This category may include:​ Patients who are deceased, or ​Patients with injuries so severe that survival is unlikely with there sources currently available. ​

Important: This does not mean the patient is abandoned.Comfort measures and appropriate care should still be provided according to the situation and available resources.​

Patient deceased, provide comfort measures​

Triage in an MCI​

pt is that triage is dynamic.​ Patients may be reassessed repeatedly because their condition can change. Always assess area before approching scene!!​

A general approach is:​

1. Ensure scene safety​
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2. Rapidly assess patients​
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3. Identify immediate life threats​
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4. Assign triage category​
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5. Provide rapid lifesaving interventions when appropriate​
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6. Reassess and reprioritize​

Bioterrorism Events​

is the intentional release or use of a biological agent—such as a bacterium, virus, or toxin—to cause illness, death, fear, or disruption in a population.​

For nurses, the focus is on recognition, safety, infection control, reporting, triage, and supportive care rather than identifying how an agent could be released.​

Common Characteristics​= events can be difficult to recognize because:​ Symptoms may initially resemble common illnesses. ​

There may be an unusual increase in patients with similar symptoms. ​

Patients may present from different locations but have similar illnesses. ​

Unusual age groups or populations may become ill. ​

There may be an unexpected geographic or temporal pattern. ​

A cluster of unexplained illness may occur.​

Contact transmission what do you need to wear for PPE?

Gloves ​

Gown ​

Droplet transmission what do you need to wear for PPE?

Surgical/procedure mask ​

Gloves/gown as indicated ​

Eye protection when splash exposure is possible ​

Airborne transmission what PPE should you wear?

Fit-tested N95 respirator or higher-level respirator ​

Appropriate isolation room/_ infection-control measures​

Important Bioterrorism Considerations​

do not spread easily from person to person. In those situations, routine precautions or precautions specific to the exposure may be appropriate.​

For example, inhalational anthrax is not generally transmitted person-to-person, so the nurse should not assume that an N95 is automatically required simply because anthrax is suspected.​

Conversely, an agent capable of airborne transmission, such as smallpox, requires appropriate airborne and contact precautions according to current infection-control guidance.​

Legal Issues in Emergency Nursing

involves rapid decisions, limited information, and high-risk situations, so nurses must understand their legal responsibilities while providing timely care.

Informed Consent​

patient receives enough information about a procedure—including risks, benefits, and alternatives—to make an informed decision.​

Usually, the provider performing the procedure is responsible for explaining the procedure and obtaining informed consent.​

Nurse's role​- The nurse generally:​ Verifies that consent has been obtained, Witnesses the patient's signature when required, Confirms the patient appears capable of understanding, Notifies the provider if the patient has unanswered questions​.

Implied Consent​

In an emergency, _ may apply when:​ The patient cannot provide consent, Immediate treatment is necessary, Delay could result in serious harm or death ​

Example:​ An unconscious patient arrives with life-threatening bleeding and cannot provide consent.​ Emergency treatment can generally proceed under implied consent, subject to applicable law and policy.​

Refusal of Treatment​

A competent adult generally has the right to _, even if the decision could result in serious harm or death.​

The nurse should:​ Assess understanding/capacity as appropriate, Explain consequences within the nurse's role, Notify the provider, Respect the patient's decision ​

Document the refusal and education ​

Important: Don't force treatment simply because the nurse disagrees with the patient's choice.​

Patient Capacity​

The nurse must recognize that an emergency patient may have impaired decision-making ability because of:​ Altered mental status, Intoxication, Head injury, Hypoxia, Shock, Severe illness ​

If the patient lacks decision-making capacity, the appropriate surrogate decision-maker or emergency consent process may apply.​

When should the RRT be called?​

when a patient has significant or worsening changes, such as:​

Finding​	Example​
Airway​	Difficulty maintaining airway​
Breathing​	Severe respiratory distress, rapidly falling SpO₂​
Circulation​	Very low BP, signs of shock​
Heart rate​	Severe tachycardia or bradycardia​
Mental status​	Sudden change in level of consciousness​
Neurologic​	New seizure or acute deterioration​
Overall concern​	“Something is seriously wrong” or the patient is rapidly worsening​

RRT vs. Code Blue​

RRT​	Code Blue​
Patient is deteriorating​	Patient has cardiac/respiratory arrest​
Goal: prevent arrest​	Goal: resuscitate​
Called before arrest​	Called when arrest occurs​
Early intervention​	CPR, defibrillation, advanced life support​

Code Blue

is the hospital emergency response for a patient experiencing cardiac arrest or respiratory arrest.​ When?​- Typically when the patient:​ Is unresponsive, Is not breathing normally or only gasping. Has no definite pulse when assessed by a trained provider ​

The team rapidly:​

1. Recognizes the arrest ​

2. Calls/activates the code ​

3. Begins CPR ​

4. Connects a monitor/defibrillator ​

5. Determines the cardiac rhythm ​

6. Provides defibrillation if appropriate ​

7. Provides ACLS medications/interventions ​

8. Secures airway/ventilation as needed ​

9. Continues until ROSC, termination of resuscitation, or transition to appropriate care​

❤ CPR — Cardiopulmonary Resuscitation​

provides circulation and oxygenation when the heart has stopped effectively pumping.​

Basic CPR sequence​

Recognize → Call for help → CPR → AED/defibrillator​

For an adult without a pulse:​

• Chest compressions: 100–120/min ​

• Depth: at least 2 inches (5 cm) ​

• Allow full chest recoil ​

• Minimize interruptions ​

• If providing breaths: 30 compressions : 2 breaths ​

Why compressions?​ Chest compressions temporarily move blood to vital organs, especially the:​ Hard + Fast + Full recoil + Few interruptions​

Defibrillation

delivers an electrical shock to the heart to stop certain abnormal rhythms so the heart can potentially return to an organized rhythm.​

is used for:​

🔴 Ventricular fibrillation (VF)​
🔴 Pulseless ventricular tachycardia (pVT)​

These are shockable rhythms.​

NOT shockable:​

⚫ Asystole​
⚫ Pulseless electrical activity (PEA)

treatment is primarily:​ CPR + epinephrine + identify/treat reversible causes​​

VF/pulseless VT → Shock​

Asystole/PEA → NO shock​​

Advanced Cardiovascular Life Support.​

It builds on basic CPR and uses advanced interventions to treat cardiac arrest and other life-threatening cardiovascular emergencies.​ may include:​ High-quality CPR, Defibrillation ​Cardiac rhythm interpretation, IV/IO access, Resuscitation medications. Advanced airway management, Capnography, Identification of reversible causes, Post-cardiac-arrest care​

Post-cardiac arrest care begins after ROSC (Return ofSpontaneous Circulation).

The goal is to prevent another arrestand minimize injury to the brain, heart, lungs, and other organs.​ 1. Airway & Breathing 🫁​= After ROSC, the patient may still be unable to protect their airway.​ The ICU team may:​ Assess airway protection. Provide oxygen and ventilatory support ​

Intubate if necessary, Use mechanical ventilation when indicated, Monitor oxygen saturation and blood gases. Avoid both hypoxemia and excessive oxygen ​

Key point: Oxygen and ventilation are carefully controlled rather than simply giving the maximum amount.​

Circulation​

The heart may remain unstable after an arrest.​ Monitor:​ Blood pressure, Heart rhythm, Heart rate, ECG, Peripheral perfusion, Urine output, Signs of shock​

Treatment may include:​ IV fluids when appropriate, Vasopressors for persistent hypotension. Treatment of arrhythmias. Evaluation for acute coronary causes ​

Goal: Maintain adequate blood flow to vital organs, especially the brain.​

Neurologic Care​

The brain is particularly vulnerable to injury after cardiac arrest.​ Assess:​ Level of consciousness, Pupillary response, Motor response, Seizure activity. Neurologic changes​

The team may use:​ EEG monitoring when indicated, Treatment for seizures, Controlled temperature management when appropriate, Delayed, multimodal neurologic prognostication ​

Temperature management​= For adults who remain unresponsive after ROSC, current resuscitation guidance emphasizesa deliberate temperature-control strategy and prevention of fever rather than allowing uncontrolled hyperthermia.​

Identify and Treat the Cause

Hs​= Hypovolemia, Hypoxia, Acidosis, Hypo-/hyperkalemia, Hypothermia​

Ts​= Tension pneumothorax, Cardiac tamponade, Toxins, Pulmonary thrombosis, Coronary thrombosis​

ICU Care​

Blood Glucose​, Monitor glucose because both hypoglycemia and significant hyperglycemia can be harmful.​ Treat abnormal glucose according to ICU protocol.​

Prevent Secondary Injury​= The ICU team focuses on preventing complications such as:​Recurrent cardiac arrest, Hypoxia, Hypotension, Fever, Seizures, Electrolyte abnormalities, Aspiration, Pressure injuries, Infection, Acute kidney injury​

Palliative Care vs. Hospice Care

Both palliative care and hospice care focus on comfort, quality of life, and relief of suffering rather than simplytreating a disease. The biggest difference is when they are provided and whether curative treatment can continue.​

Palliative Care​	Hospice Care​
Can be provided at any stage of a serious illness​	Generally provided when a person is approaching the end of life​
Can occur alongside curative or life-prolonging treatment​	Focus shifts primarily to comfort rather than curative treatment​
Does not require a terminal prognosis​	Typically requires a prognosis of about 6 months or less, if the illness follows its expected course​
Goal: improve quality of life and manage symptoms​	Goal: maximize comfort and quality of life during the final stage of life​
Can be provided in hospitals, clinics, nursing facilities, or at home​	Can be provided at home, in hospice facilities, nursing homes, or hospitals​
May continue for months or years depending on the illness​	Usually continues while the patient meets hospice eligibility criteria​

Palliative Care​

is specialized care for people living with serious illnesses. It addresses more thanphysical symptoms—it can also help with:​ Pain, nausea, shortness of breath, fatigue, and other symptoms, Anxiety, depression, and emotional distress. Spiritual concerns ​

Family/caregiver support ​

Communication about treatment goals and preferences ​

Advance care planning ​

Decisions about treatment options ​

Key point: A patient receiving palliative care can still receive chemotherapy, surgery, dialysis, or other treatments intended to cure or control the disease.​

Important Components of Advance Care Planning​

Advance directive:​ A legal document that communicates a person's healthcare wishes.​

Healthcare proxy/surrogate:​ A person designated or recognized under applicable law to make healthcare decisions when the patient lacks decision-making capacity.​

Living will:​ A type of advance directive that describes preferences for certain medical treatments if the person becomes unable to communicate.​

DNR — Do Not Resuscitate

order is a medical order stating that if a patient’s heart stops beating or they stop breathing, the healthcare team should not perform CPR or other resuscitation measures.​

 No CPR if cardiac or respiratory arrest occurs.​

• It generally means:​

• ❌ No chest compressions ​

• ❌ No defibrillation ​

• ❌ No resuscitation medications used specifically to restart the heart ​

• ❌ No intubation for resuscitation, depending on the specific order​

What DNR does NOT mean​

does NOT mean “do not treat.”​

The patient can still receive:​ Pain medication, Oxygen for comfort, Antibiotics, if consistent with goals of care, IV fluids, if desired/appropriate ​

Treatment of symptoms, Nursing care, Emotional and spiritual support. Other treatments that are consistent with the patient's wishes​.

Comfort and Symptom Management for hospice patient​

The primary nursing goal is relief of suffering.​

Assess and manage:​ Pain — administer medications as ordered and use positioning, touch, and other comfort measures. ​

Dyspnea — position for easier breathing, provide oxygen if appropriate, and administer prescribed medications. ​

Secretions — reposition the patient and provide medications if ordered; explain thatnoisy breathing does not necessarily mean the patient is suffering. ​

Agitation/restlessness — assess for pain, urinary retention, medication effects, delirium, or other causes. ​

Dry mouth — provide frequent mouth and lip care. ​

Skin discomfort — reposition gently and protect fragile skin.​

Nutrition and Hydration for hospice patient

As death approaches, the body naturally requires less food and fluid.​

Nursing care includes:​ Offer food or fluids as tolerated and desired. ​

Never force food or fluids. ​

Provide frequent oral care. ​

Explain to families that decreased intake is generally a natural part of the dying process.​

Emotional and Psychological Support​ for hospice patient?

The patient may experience fear, sadness, anxiety, or concerns about unfinished business.​

The nurse can:​ Listen without judgment. ​ Allow silence and emotional expression. ​

Provide reassurance through presence rather than making unrealistic promises. ​

Encourage meaningful communication with loved ones. ​

Respect the patient's wishes and level of alertness.​

Spiritual and Cultural Support for hospice patient?​

Ask about the patient's preferences for:​ Prayer or spiritual practices, Chaplain or clergy visits. Religious rituals ​

Family presence ​

Cultural practices surrounding dying ​

Preferred environment and personal belongings ​

Never impose the nurse's own religious or cultural beliefs.​