Telling left from right heart failure: lungs vs body — the most testable distinction
Left-sided HF (most common): left ventricle fails → blood backs up into pulmonary circulation. Signs: dyspnea (especially at rest or lying flat — orthopnea), paroxysmal nocturnal dyspnea, crackles in lungs, pink frothy sputum (severe), decreased SpO2, S3 gallop. Right-sided HF: right ventricle fails → backs up into systemic circulation. Signs: JVD (jugular vein distension), dependent pitting edema (ankles, sacrum), hepatomegaly, ascites, weight gain. Both: fatigue, decreased activity tolerance. Management: daily weights (report >2 lb gain in 1 day or >5 lb in 1 week), fluid restriction, low-sodium diet, elevate HOB, oxygen.
Left HF
Lungs — SOB, crackles, orthopnea
Right HF
Body — JVD, edema, weight gain
Monitor
Daily weight — >2 lb = call provider
Position
HOB elevated 30–45°
MI — MONA
MI treatment: MONA — Morphine, Oxygen, Nitrates, Aspirin. 12-lead ECG within 10 min. Troponin is gold standard.
Myocardial Infarction
Recognizing and responding to MI — time is muscle, every minute counts
Classic MI symptoms: crushing chest pain (may radiate to jaw, left arm, back), diaphoresis, nausea, shortness of breath. Women/diabetics: atypical — jaw pain, fatigue, nausea only. MONA: Morphine (reduces preload/pain — now questioned in STEMI), Oxygen (if SpO2 <90%), Nitrates (vasodilation — hold if systolic <90 or recent sildenafil use), Aspirin (antiplatelet — 325 mg chewed). ECG: within 10 minutes of arrival. ST elevation = STEMI — needs cath lab within 90 min. Troponin: gold standard biomarker, rises 3–4 hr after MI. Give nothing by mouth (NPO) — may need procedure.
M
Morphine — pain/anxiety
O
Oxygen — if SpO2 <90%
N
Nitrates — vasodilate, hold if BP low
A
Aspirin 325 mg chewed
Stroke — FAST
Stroke: FAST — Face drooping, Arm weakness, Speech difficulty, Time to call 911. tPA within 3–4.5 hours of onset.
Stroke Recognition and Care
Time-critical emergency — recognizing stroke and the nursing response
FAST: Face drooping (ask to smile — asymmetry), Arm weakness (raise both arms — one drifts down), Speech difficulty (slurred or unable to speak), Time — call 911 immediately. Two types: Ischemic (87% — clot) and Hemorrhagic (13% — bleed). Treatment: Ischemic → tPA (alteplase) if within 3–4.5 hours of LAST KNOWN WELL, no hemorrhage on CT. Hemorrhagic → no tPA, manage BP, possible surgery. Nursing: NIH Stroke Scale assessment, position HOB 30°, NPO until swallow evaluation, falls precautions, BP management (allow permissive hypertension in ischemic unless giving tPA). Time is brain — 1.9 million neurons lost per minute.
Two obstructive lung diseases with important differences — NCLEX loves the oxygen question in COPD
COPD (emphysema + chronic bronchitis): irreversible airway obstruction. Emphysema: barrel chest, pursed-lip breathing, decreased breath sounds, 'pink puffer' (fights to breathe). Chronic bronchitis: productive cough >3 months/2 years, 'blue bloater.' O2 in COPD: hypoxic drive — give O2 2–3 L/NC, target SpO2 88–92% (not 95–100%). High O2 may suppress respiratory drive. Asthma: reversible bronchospasm, triggered (allergens, exercise, cold). Wheezing on expiration. Peak flow meter: green >80%, yellow 50–80%, red <50%. Rescue inhaler (albuterol) before preventive (corticosteroid inhaler).
COPD O2
2–3 L, target SpO2 88–92%
Emphysema
Barrel chest, pursed lips, pink puffer
Chronic Bronchitis
Productive cough, blue bloater
Asthma
Reversible, wheezing, rescue before preventive
Pneumonia
Pneumonia assessment: fever, productive cough, crackles, decreased breath sounds. Position: semi-Fowler's. Encourage fluids and deep breathing.
Pneumonia Nursing
The most common hospital-acquired infection — assessment, positioning, and prevention
Signs: fever and chills, productive cough (yellow/green/rust-colored sputum), pleuritic chest pain (worse with breathing), crackles and decreased breath sounds in affected lobe, tachypnea, hypoxia. Community-acquired (CAP): S. pneumoniae most common. Hospital-acquired (HAP): gram-negative organisms, MRSA. Nursing care: semi-Fowler's position (HOB 30–45°), encourage fluids (2–3 L/day unless restricted — thins secretions), deep breathing and coughing exercises, incentive spirometer, turn every 2 hours, ambulate early. Prevention: pneumococcal vaccine, hand hygiene, oral care in ventilated patients (VAP bundle).
Diabetes — Hypo vs Hyperglycemia
Hypoglycemia (<70): Cold and Clammy = give candy. Hyperglycemia (>180): Hot and Dry = sugar high.
Hypoglycemia vs Hyperglycemia
The quick way to distinguish and treat two dangerous blood sugar extremes
Hypoglycemia (<70 mg/dL): Cold and Clammy — diaphoresis, tremors, tachycardia, confusion, seizure. Cause: too much insulin, missed meal, excess exercise. Treatment: 15-15 rule — 15g fast carbs (4 oz juice, glucose tablets), recheck in 15 min. If unconscious: IV dextrose (D50) or glucagon IM. Hyperglycemia (>180–250): Hot and Dry — polyuria (3 Ps: Polyuria, Polydipsia, Polyphagia), fruity breath (DKA), Kussmaul respirations (deep, rapid — blowing off CO2 in DKA). DKA (Type 1): ketones, pH <7.3. HHS (Type 2): extreme hyperglycemia, no ketones, elderly. Treatment: insulin drip, IV fluids, K+ replacement.